Patient Safety

The Patient Safety topic area of HIMSS represents the work of the HIMSS Patient Safety Task Force, which is devoted to providing best practice guidance on how Health IT can be utilized to improve patient safety.Topic areas include risk analysis, medical devices, and reducing adverse events and re-hospitalizations through Health IT.  Focus and deliverables of this Task Force will be coordinated with the efforts of the HIMSS Clinical Engineering-Information Technology (CE-IT) Community

  • An Introduction to ONC's SAFER Guides, a series of nine evidence-based toolkits that outline best practices for health care organizations to implement and utilize electronic health records and reduce the chance of an adverse event associated with Health IT. 
  • Analysis of ONC's Health Information Technology Patient Safety Action & Surveillance Plan which announced a series of initiatives designed improve reporting and data collection of HIT-related adverse events through Voluntary reporting using AHRQ’s Common Data Format, HIT Certification including adverse event reporting functionality using AHRQ Common Data Format, coupled with patient safety audits by ONC Certification bodies, and a launch of new monitoring initiatives by AHRQ, FDA, and CMS.
  • Case Studies on how hospitals are reducing the number of hospital acquired infections, adverse drug events, and rehospitalizations through the innovative use of Health IT.
  • A Complex Systems Risk Analysis Guide for the healthcare industry to understand potential errors/unintended consequences from health IT and how to avoid them.
  • Medical Device - Quick Start Guide This guide is designed to provide points of reference and consideration for the purchase and implementation of a clinical documentation system (CDS) that integrates with networked medical device systems. Since there is no one-size-fits-all system, this guide should be treated as a reference document to assist the institution in making an investment decision. This guide is intended for healthcare professionals who are responsible for technology management within their organizations and are considering the purchase or upgrade of a CDS with the added feature of medical device integration.

With the introduction of the American Recovery and Reinvestment Act in 2009, $17-$19 billion USD were earmarked to incentivize practitioners to adopt qualifying electronic health record systems in a meaningful way. Qualified EHRs, such as CCHIT-certified systems, do not include ease of use as evaluation criteria. Therefore, it is crucial that consumers of EHR technology understand the importance of human factors and the important role it plays when defining meaningful use.

The use of health information technology (HIT) can lead to unintended and unwanted consequences. This is not a new phenomenon in medicine, as iatrogenesis, or unintended harm caused by clinicians is often documented in the literature. Electronic iatrogenesis, e-Iatrogeneis, is now being documented as unintended consequences through the use of computerized provider order entry (CPOE). These consequences can include: more or new work (e.g., non-standard cases call for more steps in ordering), extended workflow (e.g., extra time to enter orders), system demands (e.g., need for continuous equipment upgrades), communication (e.g., determining when face to face discussion is needed), emotions (both positive and negative), new kinds of errors (e.g., entering orders on the wrong patient), power shifts (e.g., decisions made by ancillary clinical staff), and dependence on the system (e.g., downtime creates a major issue). Per the Joint Commission’s (JCAHO) sentinel event, “As health information technology (HIT) and “converging technologies”—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate.”


Arnol Simmons
Manager, Healthcare Information Systems
(703) 562-8826

Jonathan French
Senior Director, Healthcare Information Systems
(703) 562-8822

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