N538 Module 5 assignment: EHR safety problem-solving paper using the SAFER Guides, a full sample

The Result Nobody Owned: Using the SAFER Guides to Close the Loop on Tests Pending at Discharge

Student Name

Master of Science in Nursing Program, Aspen University

N538: Advanced Health Care Informatics

Instructor Name

Month Day, Year

The Result Nobody Owned: Using the SAFER Guides to Close the Loop on Tests Pending at Discharge

On a Friday afternoon a composite 58-year-old man was discharged from the medical unit of a 220-bed hospital after three days of treatment for cellulitis. A set of blood cultures drawn on admission was still pending. On Sunday one bottle grew gram-positive cocci. The result posted to the EHR, generated a notification to the ordering hospitalist, who was off until Tuesday, and appeared in no one else's work queue. The patient returned on Wednesday with fever and back pain.

The electronic health record did what it was built to do: it stored the result and sent an alert. The system still failed, because no person was accountable for a result that arrived after the patient had left. This paper treats that failure as an EHR safety problem. It explains the sociotechnical view of EHR safety, uses the federal SAFER Guides, whose name stands for Safety Assurance Factors for EHR Resilience, to assess the hospital's handling of tests pending at discharge, reviews the evidence on interventions, and proposes a fix that nursing can help lead.

EHR Safety as a Sociotechnical Problem

Sittig and Singh (2010) proposed an eight-dimension sociotechnical model of health information technology as it operates inside complex care organizations. Their dimensions range from the technical, such as hardware and software infrastructure, clinical content and the human-computer interface, to the social, such as people, workflow and communication, internal organizational policies, outside regulation, and the measurement and monitoring of the system itself. The dimensions interact, so safety failures seldom trace back to one cause.

The pending blood culture shows the interaction clearly. The software and the content functioned. The human-computer interface delivered an alert to one inbox. The people dimension failed because that person was off duty, the workflow dimension failed because no step at discharge assigned responsibility for pending results, and the organizational dimension failed because no policy said who should act on a result when the ordering clinician is unavailable. A fix aimed only at the software, such as a louder alert, would leave most of these untouched.

The SAFER Guides and the Test Results Assessment

The SAFER Guides, developed with federal funding, are self-assessment checklists that help organizations find EHR-related risks before they cause harm. The guides are organized into three domains: safe health information technology, using health information technology safely, and monitoring health information technology. One guide addresses test results reporting and follow-up. Sittig et al. (2022) summarized how hospitals and clinicians should approach the assessments, which the Centers for Medicare & Medicaid Services now expects hospitals in its Promoting Interoperability program to complete each year.

Adherence has historically been low. In a study by Sittig et al. (2018), eight organizations of varying size and EHR maturity self-assessed against all 140 SAFER recommendations across nine guides, and together they had fully implemented only 25 recommendations, 18% of the total, across all eight sites. Adherence was higher for recommendations about safe technology (82.1%) than for using technology safely (72.5%) and monitoring it (67.3%), a pattern that matches the pending culture case: the technology was sound and the use and monitoring were not.

For this paper, an interprofessional group at the composite hospital, including a hospitalist, a charge nurse, a laboratory supervisor, a case manager and a nurse informaticist, walked through the test results guide in one 90-minute session. Three gaps stood out. First, discharge summaries had no required field for tests pending at discharge. Second, results returning after discharge were routed only to the ordering clinician, with no rule for coverage when that clinician was away. Third, nobody monitored how often post-discharge results went unacknowledged, so the hospital had no idea how common the Sunday culture was.

How Big the Problem Is

The case is not unusual. Roy et al. (2005) studied 2,644 consecutive patients discharged from hospitalist services at two academic hospitals and found that 1,095 of them, 41%, had test results return after discharge. Of 2,033 such results, 191 (9.4%) were judged potentially actionable, and among surveyed physicians, 61.6% were unaware of the actionable results that came back. The problem is not limited to inpatient care. In an outpatient setting with an EHR that sent automated alerts for critical imaging results, Singh et al. (2009) found that 18.1% of alerts went unacknowledged and that timely follow-up was lacking for 7.7% of all alerts, a rate that was similar whether or not the alert had been read.

The second finding matters for the design of any fix. An alert that is opened is not the same as a result that is acted on. Closing the loop requires an owner and a check that the owner acted, not merely a message.

Interventions and the Proposed Fix

The evidence on interventions is modest but consistent in direction. In a systematic review of nine studies on tests pending at discharge, Darragh et al. (2018) found that six evaluated electronic discharge summary templates with a designated field for pending tests, and half of those reported significant improvement in documentation. Templates, education for discharging physicians and email alerts when results finalize all showed promise, and the authors called for combined approaches that combine better documentation with notification.

The composite hospital's fix follows that advice and adds the missing owner. At discharge, the EHR will display every test still pending and require the discharging clinician to name a responsible clinician for each one, defaulting to the hospitalist group rather than an individual. The discharge summary will list pending tests in a dedicated section that travels to the primary care practice. When a pending result finalizes after discharge, it will route to a shared hospitalist results pool that is covered every day, not to one person's inbox, and critical or positive microbiology results will also page the on-call hospitalist.

Nursing has a direct part. The discharge nurse will tell the patient which tests are still pending, who will call with the results, and what symptoms should bring the patient back, and will document that teaching in a structured field. Patients who know a result is coming are a second safety net when the first one fails.

Monitoring the Fix

Because the monitoring domain was the hospital's weakest, the plan includes three measures reviewed monthly by the patient safety committee: the percentage of discharges with pending tests that have a named responsible clinician, the percentage of post-discharge actionable results acknowledged within 24 hours, and the number of readmissions or safety reports linked to a missed pending result. The target for the first six months is that 95% of discharges with pending tests have a named owner and 90% of actionable results are acknowledged within a day. The SAFER assessment will be repeated at twelve months to confirm that the gaps are closed.

Conclusion

The blood culture that turned positive after discharge was not a software failure. It was a failure of ownership, workflow and monitoring around software that worked. The SAFER Guides gave the composite hospital a structured way to see that, and the evidence on tests pending at discharge points to a combined fix: document pending tests at discharge, assign each one an owner, route late results to a covered pool, teach patients what to expect, and measure whether it works. EHR safety, seen this way, is a nursing informatics responsibility, because nurses stand at the discharge moment where the loop either closes or opens.

References

Darragh, P. J., Bodley, T., Orchanian-Cheff, A., Shojania, K. G., Kwan, J. L., & Cram, P. (2018). A systematic review of interventions to follow-up test results pending at discharge. Journal of General Internal Medicine, 33(5), 750-758. https://doi.org/10.1007/s11606-017-4290-9

Roy, C. L., Poon, E. G., Karson, A. S., Ladak-Merchant, Z., Johnson, R. E., Maviglia, S. M., & Gandhi, T. K. (2005). Patient safety concerns arising from test results that return after hospital discharge. Annals of Internal Medicine, 143(2), 121-128. https://doi.org/10.7326/0003-4819-143-2-200507190-00011

Singh, H., Thomas, E. J., Mani, S., Sittig, D., Arora, H., Espadas, D., Khan, M. M., & Petersen, L. A. (2009). Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: Are electronic medical records achieving their potential? Archives of Internal Medicine, 169(17), 1578-1586. https://doi.org/10.1001/archinternmed.2009.263

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085

Sittig, D. F., Salimi, M., Aiyagari, R., Banas, C., Clay, B., Gibson, K. A., Goel, A., Hines, R., Longhurst, C. A., Mishra, V., Sirajuddin, A. M., Satterly, T., & Singh, H. (2018). Adherence to recommended electronic health record safety practices across eight health care organizations. Journal of the American Medical Informatics Association, 25(7), 913-918. https://doi.org/10.1093/jamia/ocy033

Sittig, D. F., Sengstack, P., & Singh, H. (2022). Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides. JAMA, 327(8), 719-720. https://doi.org/10.1001/jama.2022.0085