The introduction of health information technology (IT) has resulted in various documented improvements in patient safety and care delivery. However, unintended consequences have also emerged, and the potential for health IT to cause harm is now well recognized. This report includes 10 recommendations for research, policy, industry, and clinician users. These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to improve the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide made recommendations concerning safe implementation of electronic health records. A previous AHRQ WebM&M perspective examines the benefits and challenges of available health IT systems.

This study reports on the initial experience with an Internet-based voluntary reporting system for medication errors in ambulatory care. The system was relatively easy to use, but some participants raised concerns about error reporting leading to negative consequences for the culture of safety.

Adverse drug events (ADEs) are common in ambulatory care. One classic study estimated the incidence of medication errors in outpatients at 27 per 100 patients over a 4-week period, higher than in hospitalized patients. However, ADEs may be difficult to identify in routine practice, as patients are not monitored as closely as in the inpatient setting. This study screened electronic medical records for evidence of ADEs using several different algorithms, and identified one ADE for every seven patient-years, most of which were not considered preventable. The highest yield screening algorithms were triggers that identified patients with abnormal lab values in combination with high-risk medications. An outpatient medication error due to a pharmacy dispensing error is discussed in an AHRQ WebM&M commentary.

This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.

… The New England journal of medicine … N Engl J Med …

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc …