Health information errors cited among top 10 health IT hazards

Three of the 10 top health technology hazards cited in a report from ECRI Institute deal with errors in information management.

Making the list:

  • Patient/data mismatches in EHRs and other health IT systems, an issue on which the Bipartisan Policy Center issued a call to action in June.
  • Interoperability failures with medical devices and health IT systems.
  • Caregiver distractions from smartphones and other mobile devices.

"While many health IT implementations offer great promise for improving patient care, it must be recognized that these complex technologies also can create new paths to failure," the report states, urging healthcare facilities to pay particular attention to health IT when prioritizing their safety initiatives for 2013.

The report includes a self-assessment tool to help organizations rank their risk and plan to mitigate it, according to an announcement.

It urged organizations to plan for problems in patient/data matching while still in the planning phase of health IT projects and to take a patient-centric focus rather than a location-centric focus when equipment moves from patient to patient. It urges consideration of all possible scenarios – for instance, a device that continues to store information during a network outage could send information to the wrong patient's record once back online if it has been moved during the outage.

It urges hospitals to maintain an inventory of the interfaced devices and systems and to identify and assess risks associated with them.

Of the potential harm from caregivers' distraction by smartphones and other devices, it says:

"The potential to make mistakes or miss information is not the only concern. Caregivers who are focusing on a device's screen, rather than looking at the patient, may miss clues about the patient's condition. In addition, focusing on the device rather than the patient can lead patients to question the quality of their care."

The list includes some repeat offenders, such as unnecessary radiation exposures and medication errors while using infusion pumps. The 10 were selected according to one or all of these criteria: They resulted in injury or death; occurred frequently; can affect a large number of people; are difficult to recognize; have had widespread news coverage.

Indeed, UC Irvine Medical Center in California gained unflattering publicity last year after a kidney patient died after receiving too much medication from a drug pump. An investigation by the California Department of Public Health and the Centers for Medicare & Medicaid Services found inadequately trained staff were dispensing medication through the new infusion pumps, jeopardizing patient safety.

Worried that technology detracts from physicians' bedside manner, some medical schools are beginning to implement courses geared specifically toward helping docs integrate technology into their workflow without it hurting the doctor-patient relationship.

To learn more:
- read the report (Registration required.)
- here's the ECRI announcement