Human Limitations

"We are still in the infancy of this technology, despite what vendors will try to tell you. And although I really value HIT and see it as major contribution both to efficiency and patient safety, there are some things the technology simply has not yet mastered," says Koppel. CPOE, electronic medical records, bar coding, and radio frequency identifiers are each helpful tools, but are also still at the nascent stage that requires careful observation of their performance and vigilant examination of how and when the inevitable errors occur, he says.

With implementation of new technologies comes the need for substantial transformations in practice behavior. It also requires the involvement and cooperation of the end user. If the physicians and nurses who use it aren't able to see the value of CPOE or an EMR, they aren't likely to spend the extra time and energy to learn how to use it properly. If they haven't learned to use it properly or don't have the time to report its flaws to the vendor, they are more likely to create workarounds to get past annoying alerts or decrease the time it takes to complete a process. Those workarounds can create a whole new set of problems and increase the risk of an error occurring, says Koppel.

Bar coding is one example—many nurses have created multiple workarounds to circumvent some of the technology's flaws. For example, says Koppel, if four patients need a medication that requires refrigeration, such as insulin, and the refrigerator with the drug is on a different floor, the nurse might copy each patient's bar code to pick up the insulin doses and do the scans far from the patients' bedsides. While that may be a time-saver, by carrying four drugs with different doses on the same tray, "you have now completely obviated the protections of the bar code," Koppel says.

"The urgency of care and the ingenuity of nurses to cope with shortcomings of some of this technology has had the unintended consequence of creating medication errors. It's not a matter of staff being lazy or careless, it's that these are new technologies that don't work as well as they should yet," says Koppel.

Koppel likens the health information technology of today to the early incarnation of automobiles: They may have started out as unrefined inventions prone to breaking down every few miles, but they have evolved into much more efficient, high-performing machines. The numbers support the notion that HIT is in an emergent state. Currently electronic health records are in use in 12% of practices; CPOE is in 16%. If you remove Veteran's Administration hospitals and the largest facilities, that number is miniscule, notes Koppel. He says the resistance to adoption has less to do with finances, as is often said to be the case, and far more to do with flaws in implementation process and the technology itself.

"Vendors push this as necessary and required at this moment. I think hospital directors and physicians see it as still emerging technology and that installation can take years and be wrenching. They would prefer to have software that works better before they put their hospital or practice through hell," he says.

Ultimately, relying wholly on a computer system to prevent medical errors is problematic. Providers must strike a balance between reliance on technology and the use of their own good judgment and accountability, says Fowler. "Technology is not a cure for human fallibility. It clearly plays a crucial role in improving healthcare. The acceptance of responsibility and accountability is age old, and until human interaction is completely removed from the equation, we each must be held to high levels of accountability and responsibility."