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:
- Unintended
Consequences: Is Medication Reconciliation Next?
- Joint
Commission Sentinel Event Alert on Hazards of Healthcare IT
- Pattern
Recognition and CPOE
- Technology
Workarounds Defeat Safety Intent
- CPOE
Unintended Consequences – Are Wrong Patient Errors More Common?
- Another
Unintended Consequence of CPOE
References:
Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. The National Academies Press 2011; Released: November 8, 2011
http://www.patientsafetysolutions.com/
What’s New in the Patient Safety World Archive