Levin and others involved in health-care IT emphasize that technology isn’t the only critical factor to improving safety. Tracking errors is an essential step. Creating a national system of reporting errors, similar to that used in aviation, is one such step urged in the IOM report. Many health-care professionals also say the most important changes required are cultural since caregivers have often been reluctant to report errors out of fear of litigation or losing their job. "We need a reporting system similar to OSHA [Occupational Safety and Health Administration] or the National Transportation Safety Board so that we can understand patterns in system errors," James says. "We need to shift the focus from blame-based to ’Let’s fix the systems.’"

Others warn that pharmaceutical software and automated systems don’t always prevent errors, and that health-care providers need to remain vigilant even if they’re using computerized systems. Sylvia Bartel, director of pharmacy at Dana-Farber, says studies show that 70 percent of pharmaceutical systems have allowed fatal errors to go through. "We need to pressure vendors and the software industry to make improvements," she says. "The data is sobering; among pharmacy managers, the frustration is palpable."

Helping Hand

While computerized systems are invaluable for reducing errors, says Dr. James Bagian, director of the Veteran Administration’s national center for patient safety, health-care IT leaders need to make sure they are user-focused. "We’ve done a lot of usability testing, and we have been rewarded for that work," says Bagian, a former astronaut with two space shuttle missions to his credit.

These days, Kaiser and other large health-care networks frequently look to the country’s sprawling VA system-once maligned for shoddy care-for inspiration. Sue Kinnick, a former nurse at the VA’s hospital in Topeka, Kan., who has since passed away, came across one highly touted safety innovation completely by accident. Kinnick was returning from a convention in Seattle six years ago when she noticed a car rental agent using a handheld check-in device and thought, Why can’t we do that in the hospital?

Now the VA is using handheld scanning devices in all of its 170 hospitals as part of its widespread safety campaign. The agency tested an early version of the device in 1994 in Topeka. Four years later, a team, made up of end users and programmers from Electronic Data Systems Corp. and the VA, developed software using the Topeka VA system as a prototype. With the new system, released in August 1999, nurses roam the hospitals with units that resemble laptop computers with tethered scanners. All patients wear bar-coded identification wristbands. All medications also have bar codes. Before giving medicine to a patient, the nurse or staff member laser scans his wristband. The software verifies that the right person is receiving the right drug at the correct dosage at the right time and screens for drug interactions. If there’s a problem, the program flashes a warning. If everything checks out, the software generates an electronic record of the event.