IOM Issues 10 HIT Recommendations for Patient Safety

Cheryl Clark, November 10, 2011

Health information technology is said to be key to improving quality and safety. But even as providers rush to implement and master these expensive systems, there's an underappreciated chance that the use of computers might cause harm, according to a report from the Institute of Medicine.

"Examples of health IT–induced harm that can result in serious injury and death include dosing errors, failing to detect fatal illnesses, and delaying
treatment due to poor human–computer interactions or loss of data," the 197-page report "Health IT and Patient Safety: Building Safer Systems for Better Care" explains.

Flaws in vendor products or common misuse of them, for example, wrong drug listings in a computerized physician order entry (CPOE) system, may elude detection and sharing because of manufacturer confidentiality or non-disclosure agreements that vendors make purchasers sign, the report says.

"Thus, some vendors may impose or enforce such restrictions in ways that
may conceal patient safety issues. As long as vendors may restrict the release of information about safety issues through confidentiality clauses, intellectual property protections, and hold harmless clauses, the healthcare community will be limited in its understanding of how health IT affects
patient safety," the report says.

The report provided one example of an elderly patient who was harmed by an overdose of potassium chloride because of flaws in a CPOE system. The physician used the coded entry field to write the prescription order, but tried to limit the dose by writing an instruction in a comment box.


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