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HIT Errors 'Tip of the Iceberg,' Says ECRI

Cheryl Clark, for HealthLeaders Media, April 5, 2013

Zimmer noted that errors are of two types:

  • Those caused by humans and their interaction with electronic devices such as computers, such as when an operator fails to log off or retrieves the wrong patient record;
  • Those caused by machines that move too slow, can't communicate, malfunction, and crash.

The human factor
The report blames 56% of the errors on computers, and 46% on humans' interface with those computers.

Zimmer noted that when healthcare systems convert from paper records to electronic ones, they often discard visual cues that staff have learned to rely on, resulting in confusion and mistakes.

For example, when a hospital emergency room went from paper to electronic records, it abandoned a white board, with big circles marked with an x, when doctors had used to signal to nurses when a patient should be discharged.

"Now, you don't have a whiteboard, you don't have the visual cue. It's now in a computer. And you need to let someone know where they could put this type of information so everyone in the ED would now have access to it," she says. "People don't realize that other people rely on these visual cues. You are truly changing the mode of communication when you go from paper to a computer screen," she says.

ECRI is currently evaluating a similar, and much larger list of reports from many of the 800 hospitals that contract with ECRI's PSO services.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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