The errors are classified, described, ranked, and analyzed in a 40-page "Deep Dive" report on health information technology errors. It documents with real cases what was described in a November, 2011 report from the Institute of Medicine, Health IT and Patient Safety: Building Safer Systems for Better Care.
As health systems rapidly move from paper to electronic records, upgrade their systems from one version to the next, or incorporate different vendors across various departments or service lines, mistakes are happening that are often go hidden for months and even years, Zimmer says.
A forgotten lab test that wasn't carried over, and nursing and system manager work-arounds that fail are commonplace. Human error happens when systems depend on people to manually enter information from one system to another.
"One health system did an upgrade of its health IT system, and down the line, realized a printout of a report omitted certain fields," added Cynthia Wallace, ECRI's Senior Risk Management Analyst. "They weren't aware of that until they needed to use those reports. They realized that an upgrade two years ago had caused the omission, and was never totally tested."
Zimmer says that this analysis "really highlights the importance of reporting. Because this affords us the chance to focus health systems' attention on these issues, and suggest some strategies."
One important message from these incidents, whether health systems are starting an electronic information technology system from scratch or introducing an add-on, or making any kind of change, is that they should spend time walking through three stages: planning, implementation and ongoing monitoring to review the workflow and processes. "This should not be a one-time checklist," Zimmer says, but a system for continuous checking to recognize what limitations are in the new system.