Author Affiliations: University of Texas–Memorial Hermann Center for Healthcare Quality & Safety, National Center for Cognitive Informatics and Decision Making, School of Biomedical Informatics, University of Texas Health Sciences Center, Houston (Dr Sittig); Houston VA Health Services Research and Development Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey VA Medical Center and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston (Dr Singh).
Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives.
Sittig DF, Singh H. Defining Health Information Technology–Related ErrorsNew Developments Since To Err Is Human. Arch Intern Med. 2011;171(14):1281-1284. doi:10.1001/archinternmed.2011.327