What Can Be Done to Protect Patients from Health IT Errors?

Health care is not as safe as it should be: medical errors are a common and well-known problem. In fact, the Institute of Medicine has estimated that up to 98,000 Americans die in hospitals each year as a result of medical errors. While there are no statistics on adverse patient events resulting from health information technology (health IT) errors, such mistakes do happen which is why Abt Associates has developed a new software tool to monitor and address health IT hazards. 
 
The tool, the Health IT Hazard Manager, developed for the Agency for Healthcare Research and Quality (AHRQ) “can alert health industry professionals to potential health IT-related patient safety events before they happen,” said Andrea Hassol, principal associate at Abt who directed the project. “Essentially, it shifts the focus from reporting incidents to anticipating them before they occur and harm a patient.”
 
Hassol said there are thousands of possible health IT hazards. Examples include the unintentional duplicate ordering of a drug for a patient, both intravenously and orally and orders intended for one patient being placed for another.
 
According to Hassol, the Health IT Hazard Manger tool can help health professionals identify and communicate health IT hazards, understand their causes and how they could harm patients, pinpoint the level of urgency needed to control them, and outline steps to correct them.
 
In developing the tool, Hassol said creating a common hazard vocabulary, or ontology, was a key priority. “We wanted to ensure that stakeholders could discuss and resolve hazards using the same terminology and share information in a secure way.”
 
The Health IT Hazard Manager was beta-tested by Abt over a six-month period in 2011. The beta-test included an analysis of 495 hazards entered by the study site participants. Results were recently delivered to AHRQ in a report entitled “AHRQ’s Health IT Hazard Manager Beta-Test: Final Report.” The report can also be found on Abt’s website.          
 Abt’s work on the Health IT Hazard Manger was supported by two partners. James Walker, M.D., Chief Health Information Officer at Geisinger Health System, was the principal investigator on the project and conducted the alpha-test of the hazard vocabulary at Geisinger. The ECRI Institute’s Patient Safety Organization programmed the software and operated the Health IT Hazard Manager during the test, so that all information the test participants submitted would be protected.
 
“The testing of the Health IT Hazard Manger demonstrates its potential to diminish health IT hazards for patients nationwide,” said Scott Royal, Ph.D., vice president of Abt’s U.S. Health Division. “This tool could be the underpinning of a national Health IT safety program that can significantly advance the quality of the nation’s health care system."