Human Limitations

Kathryn Mackenzie, for HealthLeaders Magazine , January 13, 2009
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Many health IT systems promise to reduce medical errors, and they often do if used properly. But that's a big if.

One of the main selling points of health information technology is its ability to reduce medical errors. Each week it seems there is a new gadget on the market that promises to decrease the likelihood that a patient will be given the wrong medication or that a sponge will be left inside someone after surgery. What is often forgotten in the hype, however, is that the technology's effectiveness in error reduction hinges on the human ability to create, instruct, and use that technology appropriately.

"If you can replace human action with a flow of data—and the data is input and defined properly—technology will perform a given function over and over flawlessly. But it's also like a high-speed idiot: If it is programmed improperly, it will improperly perform that function," says Andrew Fowler, chief information officer for Methodist Le Bonheur Healthcare in Memphis, TN.

Discussions about health information technology's effectiveness generally assume that it operates in a realm of its own. But it's important to remember that it is used within a system by physicians, nurses, and other clinicians who invariably have different levels of training, says Fowler. "Most users don't have much to do with the development of the technology, so as long as humans are still required to interact with it, it's going to take a good deal of training and education to keep errors from happening," he says.

Take computerized physician order entry systems. CPOE is widely hailed as a primary contributor in reducing medical errors. It has been shown to decrease adverse drug events by as much as 80%. It eliminates extra work for nurses and pharmacists who no longer have to spend time interpreting illegible handwritten orders. It improves workflow and leads to better distribution of information when compared to paper-based systems. But all of those benefits have to be taken in context, says Ross Koppel, professor at the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine. "HIT helps in terms of efficiencies and patient safety, but it also introduces the potential for errors that must be addressed," Koppel says.

A study conducted over a two-year period by Koppel and a team of his colleagues found that the CPOE system at one tertiary care teaching hospital created 22 types of previously unidentified medication error risks. Examples include fragmented CPOE displays that prevent a complete view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double-dosing and incompatible orders, and inflexible ordering formats generating wrong orders, according to the report.

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