There is little doubt that sizable financial investments will be needed to build the national health information infrastructure. It was beyond the scope of this study to develop estimates of the resources required to accomplish the agenda proposed herein or to evaluate alternatives for providing these resources. The conduct of such an analysis represents an important next step that should be pursued immediately.

Once the basic health information infrastructure has been built, the health care sector should be able to function at a far higher level of safety and efficiency. Many of the factors that lead to errors (e.g., illegible handwriting in clinical records, mistakes in calculating drug dosages, lack of access to information on a patient’s known drug allergies) will have been eliminated. Although human analysis of errors that do occur will still be necessary, the information technology infrastructure should greatly reduce the human effort currently required to identify and analyze most errors. Over time, the infrastructure, including health care data standards, will need to evolve to accommodate developments in medical knowledge, technological innovations, and social changes in the way patients and their families interact with the health care delivery system.

Although building the information technology infrastructure is critical to both error prevention and error reporting, the elegance of implementing an EHR system is that it is a single solution to both objectives. Investment in EHR systems is critical to applying much of the knowledge that already exists about error prevention. Robust internal and external reporting systems for near misses and adverse events provide new knowledge that makes it possible to design even safer delivery systems. In building their EHR systems, health care organizations may want to target initial investments to the establishment of key capabilities for which a sizable knowledge base already exists with regard to the prevention of errors (e.g., medication order entry systems significantly reduce medication errors) and in areas in which computerized data will be useful in detecting and analyzing errors. All health care providers should also derive benefits in the near future from AHRQ’s efforts to establish standardized error reporting requirements and to conduct applied research that will lead to enhanced knowledge and tools that can be used to improve patient safety.


The committee apologizes for the heavy use of acronyms in the Executive Summary and the report itself. Both spoken and written discussion on health care data standards are replete with acronyms. To help the reader, a

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