What’s New in the Patient Safety World

December 2011

IOM Report on Health IT and Patient Safety


We’ve written frequently about the unintended consequences of CPOE and other high tech interventions. Even as we undergo the inexorable journey to electronic health records, the healthcare industry has begun to recognize that new technologies, while solving many problems, also bring new problems with them.


Now the Institute of Medicine (IOM) has released a new report: Health IT and Patient Safety: Building Safer Systems for Better Care advocating better systems to monitor the impact of health IT on patient safety, including dissemination of lessons learned from the unintended consequences of HIT.


The report calls for an independent federal entity to investigate deaths, serious injuries or unsafe conditions associated with health IT similar to the way the National Transportation Safety Board investigates transportation accidents.


It also calls for removal of “gag” clauses and “hold harmless” clauses that are commonly included in contracts with medical software vendors and which might impede dissemination of lessons learned from adverse events involving HIT.


The report clearly notes that not all the patient safety issues resulting from HIT are the fault of the software, per se, but rather that the human-user interface and how clinicians and other users react to the software are equally important. We’ve often commented on how overreliance of “the computer” to do the right thing leads providers down a path destined to produce errors and adverse outcomes.


The report does give examples of some of the unintended consequences of HIT and also how lessons learned can be used to help design and implement better systems. For example, they describe how researchers learned from a rocky implementation of CPOE in Pittsburgh to implement much more smoothly CPOE in Seattle.


The report has good discussions about multiple technologies, including CPOE, bedside medication verification (barcoding), clinical decision support tools, medication management systems, patient engagement tools, and others. Though the literature on adverse effects of HIT is limited, they do provide an extensive bibliography of what studies are available. They provide good discussion about how users react to HIT, including workarounds.


Lastly, they have good discussions about HIT design and implementation with patient safety in mind and call for more intensive interdisciplinary research going forward.




See also some of our prior Patient Safety Tip of the Week columns on unintended consequences of healthcare IT:







Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. The National Academies Press 2011; Released: November 8, 2011
















Tip of the Week Archive


What’s New in the Patient Safety World Archive