In an effort to examine IT-related adverse events, the ONC analyzed Common Formats for patient adverse event reporting from the ECRI Institute and University HealthSystem Consortium.
Here are seven characteristics, factors and findings regarding IT-related adverse events.
1. In the ECRI database, 96 percent of reported adverse events did not answer the following question: Was health IT implicated in the event?
2. Of the reports that did include a response to the previous question, 75 percent said no, 19 percent were unsure and 5.5 percent said that health IT did play a role in the event.
3. In the ECRI database, there were 755 reported health IT events, 68 percent of which were classified as incidents, 15 percent as near misses and 18 percent as unsafe conditions.
4. Communication among staff and team members were the most common contributing factors to health IT-related events, accounting for between 40 and 42 percent of reported adverse events, followed by staff inattention (33-34 percent), accuracy of data (21-23 percent) and availability of data (10-12 percent).
5. Medication-related events were the most common type of health IT-related event, representing one-third of events.
6. UHC data indicated clinical documentation systems, computerized provider order entry and laboratory information systems were the systems most commonly involved in adverse events.
7. Additionally, UHC found that approximately 31 percent of adverse events indicated as being health IT-related were not so, and more than 25 percent of events that were health IT-related were not coded to reflect that.
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