HIT Errors 'Tip of the Iceberg,' Says ECRI
"If a system doesn't fully meet the (healthcare system's) needs, you don't want to leave an individual to come up with his or her own customized workarounds," she explains. "These are symptoms of suboptimal systems designs, and if you have a lot of them, you need to understand why staff adopt them and address their concerns."
The 36 hospitals that participated in the ECRI IT project are among the hospitals around the country for which ECRI serves as a Patient Safety Organization, or PSO.
PSOs are covered under a special federal law that allows hospitals to report incidents, near misses, and unsafe conditions immune from legal discovery and absent patient identification so those protections will encourage reporting of system and human mistakes without prompting blame, publicity, or litigation.
The 171 events documented, break down like this:
- 53% involved a medication management system.
- 25% involved a computerized order entry system
- 15% involved an electronic medication administration record
- 11% involved pharmacy systems
- 2% involved automated dispensing systems
- 17% were caused by clinical documentation systems
- 13% were caused by Lab information systems
- 9% were caused by computers not functioning
- 8%. Were caused by radiology or diagnostic imaging systems, including PACS
- 1% were caused by clinical decision support systems
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