ECRI Institute PSO Uncovers Health Information Technology-Related Events in Deep Dive Analysis

Feb 06, 2013, 14:51 ET from ECRI Institute

Data transfer, data entry, system configurations, and more identified as serious problem areas

PLYMOUTH MEETING, Pa., Feb. 6, 2013 /PRNewswire-USNewswire/ -- The federal government is spending about $19 billion to encourage hospitals, physician practices, and other healthcare organizations to invest in their health information technology (HIT) infrastructure with the goal of improving patient safety and quality through the Health Information Technology for Economic and Clinical Health (HITECH) Act.


Concerned about the unintended consequences of HIT and the potential for errors to cause patient harm, ECRI Institute Patient Safety Organization (PSO) recently conducted a PSO Deep Dive™ analysis on HIT-related safety events. Their just-released 48-page report identified five potential problem areas, which can be assessed with the accompanying toolkit. The report and toolkit are available for purchase without membership in ECRI Institute PSO.

"Minimizing the unintended consequences of HIT systems and maximizing the potential of HIT to improve patient safety should be an ongoing focus of every healthcare organization," says Karen P. Zimmer, MD, MPH, FAAP, medical director, ECRI Institute PSO.

Based on reports submitted to the PSO from participating organizations, ECRI Institute PSO experts identified the following key HIT-related problems:

  • inadequate data transfer from one HIT system to another
  • data entry in the wrong patient record
  • incorrect data entry in the patient record
  • failure of the HIT system to function as intended
  • configuration of the system in a way that can lead to mistakes

To collect enough reports for meaningful evaluation, ECRI Institute PSO asked participating organizations to submit standardized data about HIT events during a nine-week period. This enabled ECRI Institute PSO to identify patterns and trends from the aggregated data and share the findings, as well as its recommendations. The data in the PSO Deep Dive represents only that collected using the Agency for Healthcare Research and Quality (AHRQ) HIT Common Formats. ECRI Institute PSO data encompasses over 800 HIT-related events.

According to the report, HIT must be considered in the context of the environment in which it operates during the three phases of any HIT project: planning for new or replacement systems, system implementation, and ongoing use and evaluation of the system. "Shortsighted approaches to HIT can lead to adverse consequences," caution the authors.

"Healthcare organizations should consider the findings and recommendations in the PSO Deep Dive as part of their effort to achieve those goals," adds Zimmer.

The HIT PSO Deep Dive findings were published in a 48-page report and toolkit with self-assessment questionnaire and action plan form available to all ECRI Institute PSO Members and its partner PSO members. The table of contents of the report is available for free viewing/download. Additional information will be presented in ECRI Institute PSO's Monthly Brief free e-newsletter March edition; go to to sign up. The full report and toolkit are also available for purchase.

For questions about this topic, or for information about purchasing the report, please contact ECRI Institute PSO by telephone at (610) 825-6000, ext. 5558; by e-mail at; by fax at (610) 834-1275, or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.

About ECRI Institute
For 45 years, ECRI Institute's work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. The ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit Find ECRI Institute on Facebook ( and Twitter (