ECRI Institute Launches Health IT Hazard Reporting System

The hazards collected are used to help create safety proactively by finding and fixing health IT-related hazards before they contribute to user errors.

Nonprofit health IT organization ECRI Institute's Patient Safety Organization (PSO) announced the release of a health IT hazard reporting system, which uses Agency for Healthcare Research and Quality (AHRQ) common formats and a tested standardized taxonomy for health IT hazard information.

The ECRI Institute PSO reporting system collects IT hazards through the Internet in a centralized and standardized way, allowing for the identification of specific types of hazards and the ability to show data trends.

The hazards collected are used to help create safety proactively by finding and fixing health IT-related hazards before they contribute to user errors, care-process compromise or patient harm.

The organization integrated the taxonomy into its event-reporting platform and is collecting information to help health care organizations systematically track the root cause of health IT-related hazards and manage these risks.

Health IT encompasses information systems such as electronic health records (EHRs), the hardware and software that support human interactions with those systems, such as notebooks, tablets, smartphones and mobile health apps, and the interfaces that allow a dialogue between medical devices and other systems.

"Well-designed, well-implemented health IT has the potential to help health care organizations improve care and patient outcomes, but too often, health IT is implemented without full understanding of the work environment and results in risks," Dr. Karen P. Zimmer, medical director, ECRI Institute PSO, said in a statement.

The health IT hazard taxonomy—known as the Health IT Hazard Manager—was developed and piloted in a federally funded project led by Abt Associates with ECRI Institute and Geisinger Health System's Patient Safety Institute.

"It is important to understand the nature of health IT hazards, defined as any characteristic of health IT or its interactions with other systems—including humans—that increases the likelihood of compromised care-process and patient harm," Zimmer added. "It is equally important to correct health IT systems to reduce or avoid such risks."

Earlier this year, ECRI Institute PSO issued a Deep Dive on Health Information Technology, which examined adverse events and near misses associated with the electronic health record and related technologies.

The organization also released its top ten health IT hazards of 2013, which included patient and data mismatches in EHRs and other health IT systems, interoperability failures with medical devices and health IT systems, inadequate reprocessing of endoscopic devices and surgical instruments, and caregiver distractions from smartphones and other mobile devices.

"The list is not comprehensive nor will all of the hazards listed here be applicable in all health care facilities," the report noted. "We encourage facilities to use the list as a starting point for patient safety discussions and for setting their health technology safety priorities."