| Abstract | BACKGROUND: Increasing data suggest that error in medicine is frequent and results in substantial
harm. The recent Institute of Medicine report (LT Kohn, JM Corrigan, MS Donaldson, eds: To Err Is
Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999) described the
magnitude of the problem, and the public interest in this issue, which was already large, has grown.
GOAL: The goal of this white paper is to describe how the frequency and consequences of errors in
medical care can be reduced (although in some instances they are potentiated) by the use of information
technology in the provision of care, and to make general and specific recommendations regarding error
reduction through the use of information technology. RESULTS: General recommendations are to
implement clinical decision support judiciously; to consider consequent actions when designing systems; to
test existing systems to ensure they actually catch errors that injure patients; to promote adoption of
standards for data and systems; to develop systems that communicate with each other; to use systems in
new ways; to measure and prevent adverse consequences; to make existing quality structures meaningful;
and to improve regulation and remove disincentives for vendors to provide clinical decision support.
Specific recommendations are to implement provider order entry systems, especially computerized
prescribing; to implement bar-coding for medications, blood, devices, and patients; and to utilize modern
electronic systems to communicate key pieces of asynchronous data such as markedly abnormal
laboratory values. CONCLUSIONS: Appropriate increases in the use of information technology in health
care- especially the introduction of clinical decision support and better linkages in and among systems,
resulting in process simplification-could result in substantial improvement in patient safety. |