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With the introduction of Health Information technology, the potential for unintended consequences can occur. Island Health developed a Quality Assurance review process to evaluate and identify opportunities for system optimization, education and engagement, policy changes, as well as identify unintended consequences of Electronic Health Record (EHR) implementations. The Patient Safety Learning System was utilized to audit and evaluate reported safety events for system breaks and opportunities, practice and policy, as well as workflow implications. The findings were then reported to the reporter, leadership, and through governance structures. This process identified that 242 reported patient safety events in 1 year has resulted in 30 (13.7%) of these events leading to EHR System optimization. Ultimately Island Health's Nurse Informaticists foster a culture of safety through their QA/QI Patient Safety event investigations which improve system usability and ultimately Patient Safety.
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