The potential for health information technology (IT) to improve health care delivery has been appreciated for decades, but "digitizing" health care can also introduce new risks and even harm. As the use of health IT has grown, these risks have become more apparent. The authors of this report evaluated the efforts of 11 hospitals and ambulatory practices to use an improvement strategy and tools developed to promote safe use of health IT and to diagnose, monitor, and mitigate health IT–related safety risks. Through interviews, the authors discovered that some health care organizations (especially hospitals) with expertise in process improvement were able to identify and begin to mitigate health safety risks, but in most others, awareness of these risks was limited (especially in ambulatory practices). The authors concluded that better tools like the recently released Safety Assurance Factors for EHR Resilience (SAFER) Guides are needed to help organizations optimize the safe use of health IT. However, health care organizations will require a better understanding of the safety risks posed by electronic health record (EHR) use to take full advantage of the SAFER Guides. There may also be a need for additional tools and metrics (and further usability studies of existing tools and metrics) to better support the needs of health care organizations as they increasingly rely on health IT to improve the quality and safety of patient care.

Please note: This report is not available on the RAND website but can be downloaded from the healthit.gov website.

Table of Contents

  • Chapter One

    Background

  • Chapter Two

    Implementation of Health IT Safety Risk Projects

  • Chapter Three

    Evaluation

  • Chapter Four

    Results

  • Chapter Five

    Lessons from the Pilot Project

  • Chapter Six

    Discussion

  • Appendix A

    ECRI Institute PSO Adverse Event Analysis

This report was sponsored by the U.S. Office of the National Coordinator for Health Information Technology, and was conducted within RAND Health, a division of the RAND Corporation.

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