Despite the teflon coating EHR manufacturers attempt to apply product safety caveats via slick mouthed, bifurcated lingual constructs and end user license agreements, the reality is patients are tethered to care delivery systems that can, and do fail.

If harm befalls a patient the event should be reported, the report should fundamentally state “this is an event”. This should not be the jump point for an algorithm of denial and concealment;

EXAMPLE
” If patient harmed, Jump (do this): deny then conceal;
Deny;
Conceal;
End”

We would like to see development in the patient safety area for better product safety testing of information systems specifically related to patient safety. As the healthcare environment continues to move toward PC convergence and integration with EHR/EMR’s, the need for continuous quality improvement does not decrease. We have only shifted stress and created new risk complexities that require our attention.

Conclusion: Funding for safety testing should be increased in proportion to complexity. This means care and planning that can only come from understanding.

More participation is needed from Greg Smith’s community.

1. Microshock.
When a computer (such an EMR in an Operating Room or Intensive Care Unit) is connected to monitors that have an invasive component – such as CVP, Swan Ganz or Intra Arterial pressure monitors – if the equipment is not well grounded – there is a danger of MICROSHOCK. Patient’s life is in danger at a much lower electrical current leakage, actually in the order of magnitude thousands of times lower than say, regular electrical shock thru the skin. This danger is the result of the catheter(s) being inside a blood vessel and providing an excellent conducting medium – salty blood – directly to the heart. What makes the above situation even nastier – is the difficulty in making the right diagnosis, of a patient suddenly developing arrhythmias while being under anesthesia / critical care….There are so many other diagnosis to consider and so little time to react that microshock usually proves fatal.

2. Optical coupler
Years ago, when we decided to hook a printer to a monitor in the OR and that monitor had an invasive component as detailed above we employed an optical connector…It basically transfers the information using an optical mechanism, thus achieving electrical safety and still maintaining the information transfer.