Health IT Biggest Threat to Patient Safety, Report Says

Ken Terry

April 24, 2014

Health information technology (IT)-related safety hazards topped the ECRI Institute's first annual list of the Top 10 Patient Safety Concerns for Healthcare Organizations. The list was based on more than 300,000 event reports, research requests, and root-cause analyses submitted to ECRI's patient-safety organization.

Other areas that pose threats to patient safety, the report said, include poor care coordination during transitions to patients' next level of care, test result reporting errors, drug shortages, failure to adequately manage behavioral health patients in acute care settings, mislabeled specimens, retained devices and unretrieved fragments, patient falling while toileting, inadequate monitoring for respiratory depression in patient taking opioids, and inadequate reprocessing of endoscopes and surgical instruments.

Seeking to explain why health IT stood out from these other issues, the report noted that the use of electronic health records (EHRs) more than tripled from 2009 to 2012, partly because of the federal EHR incentive program. "Health IT systems are very complex," said James P. Keller, vice president of technology evaluation and safety for the ECRI Institute, in the report. "They are managing a lot of information, and it's easy to get something wrong" if the systems are not designed and implemented well.

The integrity of data in health IT systems, the report said, can be compromised by any of the following:

  • data entry errors,

  • missing data or delayed data delivery,

  • inappropriate use of default values,

  • copying and pasting older information into a new report,

  • use of both paper and electronic systems for patient care, and

  • misattribution of one patient's data to another patient.

Training, Testing Necessary

To safeguard the integrity of electronic data, the report recommended testing each system and its associated interfaces. "We need to test the system to ensure the computer system operates as intended," Karen Zimmer, MD, medical director for ECRI's patient-safety organization and its patient safety risk and quality group, told Medscape Medical News. "We've seen situations where organizations implement system upgrades, and this will cause the system to operate in unintended ways." In addition, she noted, interfaces may not work as intended, or changes in 1 system may cause unanticipated problems in other systems.

ECRI also urges healthcare organizations to provide sufficient user training on health IT systems. However, Dr. Zimmer cautioned, "We found that inadequate training is only one contributing factor in these safety issues. Many events are related to system and computer configuration. There are instances where interfaces between order entry systems and pharmacy systems have been inadequate in terms of data transfer."

Dean Sittig, PhD, a health IT expert who teaches at the University of Texas Health Sciences Center in Houston, agreed that better training is not a panacea, but for a different reason. No matter how well trained clinicians are, he told Medscape Medical News, "they have a lot to do, and telling them to be careful isn't adequate" to prevent safety problems. For example, he noted, "We build in all these alarms to help them, but we've overwhelmed them with the number of alarms."

Dr. Sittig was not surprised that health IT is the number one safety problem on the ECRI list. "We're creating an [health IT]-enabled healthcare system. It's become a huge part of almost every aspect of healthcare. It's not just electronic records. For example, almost all of the devices in the hospital now have computers in them, and most are connected to a network."

But some safety problems are directly traceable to EHRs. For example, the ECRI report cited incorrect and missing data in EHRs as a barrier to safety, because physicians who rely on those records may have an incomplete knowledge of the patient's situation. If an allergy is not entered into the record, for example, a physician might prescribe a contraindicated drug, noted Dr. Zimmer.

She added that IT systems themselves can cause issues by being hard to use. "We've seen [patient safety] events that resulted from how people interacted with the system: How many screens or how many clicks does the end user have to go through to get to that information? How easy is it to read the screen format?"

ECRI recommended organizations establish a mechanism for clinicians to report safety-related health IT problems as they are discovered. That is fine if they can identify these problems, Dr. Sittig countered. "But most people don't know that an error has occurred in the system. It's very difficult to recognize these errors."

For example, he said, a physician might order a medication in the computerized physician order entry system, but when the order gets to the pharmacy, it is for a different medication. The pharmacist does not know that the order is incorrect, the physician never sees it again, and the nurse administers the drug thinking the physician ordered it. Nobody would know that the error was in the system.

Despite all of the safety issues raised in the report, Dr. Zimmer stated, "Overall, there's a real benefit to health IT. But it needs to be implemented and designed properly."

Added Cindy Wallace, a senior risk management analyst at ECRI, "The benefits outweigh the risks. We know the risks are there, and we need to take steps to address those risks."


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