Cyber Risks in Healthcare: Partnering for Safety
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1 Organised by Cyber Risks in Healthcare: Partnering for Safety Ronni P. Solomon Executive VP and General Counsel ECRI Institute
2 ECRI Institute Independent, not-for-profit applied research institute Healthcare safety, quality and effectiveness 45-year history, 400 person staff Evidence-Based Practice Center Patient Safety Organization (PSO) Collecting, analyzing over 3.5 million adverse events and near misses Convened Partnership for Health IT Patient Safety HIMSS Europe GmbH 2
3 Multi-stakeholder Partnership Convened in 2014
4 HIMSS Europe GmbH 4
5 Do you think your EHR or the way it s used has been associated with adverse events in your organization? HIMSS Europe GmbH 5
6 HIMSS Europe GmbH 6
7 Case 1: System Availability The surgeon tried to access a patient s radiology study from the PACS system in the OR. The display would only show a blue screen. The patient s time under anesthesia was extended while staff tried to get the computer display to work. Health IT issue? HIMSS Europe GmbH 7
8 Case 2: Weight-Based Dosing On admission the patient s weight was documented as 40 kg; the patient actually weighed 40 pounds. The EHR allows weight to be entered in kilograms or pounds. The patient s medication dose was calculated based on the patient s weight in kilograms. Pharmacy caught the error and corrected the dose based on the patient s true weight. Health IT issue? Report? HIMSS Europe GmbH 8
9 Case 3: Auto-Selected Dosages Provider begins to enter medication dose. Typed 10 for 10 MG dosage. Highlighted list appears, software auto-selected 100. The provider selects the highlighted dosage. HIMSS Europe GmbH 9
10 Case 4: Practice Makes Perfect A physician logged in from home thinks he has logged into the test EHR but is actually in the production EHR. He pulls up a patient s record at random and practices entering several orders and notes. The patient gets discharged with several sham drug orders. Health IT issue? HIMSS Europe GmbH 10
11 Case 5: Prescribing EpiPen A key word search was conducted to order an EpiPen for an adult patient. The key word search brought up only the pediatric dose, not the adult dose as was intended. HIMSS Europe GmbH 11
12 Who is Responsible? HIMSS Europe GmbH 12
13 Who is Speaker twitter handle EHR Developers: Safety in design Developers & Providers: Safety in implementation SHARED RESPONSIBILITY! Providers & Users: Safety in use HIMSS Europe GmbH 13
14 Partnership Goals Making health IT safer together by: Establishing a non-punitive environment for sharing and learning Testing a collaborative model for collecting and analyzing safety issues Achieving robust stakeholder engagement Sharing best practices and lessons learned Informing the national safety strategy for health IT HIMSS Europe GmbH 14
15 The Safety Roadway What events happen Why do they happen How can we improve HIMSS Europe GmbH 15
16 A Multi-Stakeholder Speaker twitter handle HIMSS Europe GmbH 16
17 Health IT Safe Practices: Safe Use of Copy and Paste Safe Practices Evidence Review Toolkit Tools Resources HIMSS Europe GmbH 17
18 Safe Practice Recommendations for Copy and Paste Recommendation A: Provide a mechanism to make copy and paste material easily identifiable. Recommendation B: Ensure that the provenance of copy and paste material is readily available. Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste. Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed. HIMSS Europe GmbH 18
19 The Right Solutions are Not So Speaker twitter handle HIMSS Europe GmbH 19
20 Top Ten Patient Safety Concerns HIT HIT HIT HIT HIMSS Europe GmbH 20
21 Organised by THANK YOU! Ronni P. Solomon VP and General Counsel ECRI Speaker twitter handle
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