ECRI Institute’s Partnership for Health IT Patient Safety Releases New Recommendations to Avoid Testing and Medication Mix-ups

Publicly available report offers important tools and guidance for all healthcare systems

July 26, 2018

PLYMOUTH MEETING, PA—The Partnership for Health IT Patient Safety a multi-stakeholder collaborative convened and operated by ECRI Institute, released a new report, Health IT Safe Practices for Closing the Loop, today that identifies ways that technology can reduce and eliminate errors from diagnostic testing and medication mix-ups.

The Partnership leverages the work of multiple Patient Safety Organizations (PSOs), along with providers, vendors, an expert advisory panel, and collaborating organizations to create a learning environment that mitigates risk and facilitates improvement. This new report is the fourth in a series of safe practices toolkits published by the private-sector Partnership since 2014.

Health IT Safe Practices for Closing the Loop is based on reported events in ECRI Institute PSO's database of more than 2 million adverse events, an evidence-based literature review, and methodical analysis by a Partnership workgroup. The toolkit is available for use by healthcare systems worldwide.

In keeping with the goal of collaboration to make health IT safer, the Partnership convened a workgroup, chaired by Dr. Christoph U. Lehmann of Vanderbilt University, to address safety issues related to tracking diagnostic test results and medication changes. This issue, often referred to as "closing the loop," has long been a challenge in all practice settings.

"The problem of not closing the loop has a significant impact on patients and care givers, and can lead to devastating effects on the outcome of patients," states Lehmann, Partnership expert advisory panel member and workgroup chair.

Specifically, the workgroup focused on identifying ways for health IT to mitigate missed, delayed, and incorrect diagnoses on diagnostic testing results and medication changes. The report includes detailed implementation strategies based on the following three key safe practice recommendations:

  1. Develop and apply IT solutions to communicate the right information (including data needed for interpretation) to the right people, at the right time, in the right format
  2. Implement health IT solutions to track key areas
  3. Use health IT to link and acknowledge the review of information and the documentation of the action taken

“The goal of this Partnership workgroup was to look for technology solutions that all stakeholders could implement to close the loop—the tools provided here will help to do just that," says ECRI Institute's Lorraine Possanza, DPM, JD, MBE, program director.

The Partnership is sponsored in part through funding from the Gordon and Betty Moore Foundation.

To learn more, contact us by telephone at (610) 825-6000; by e-mail at; or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462.

Social Sharing

  • #HealthIT Safety Collaborative releases new safe practices for closing the loop on tracking test results and medication changes
  • #HITPartnership, w/ @ECRI_Institute, release new Safe Practice recommendations

About ECRI Institute
ECRI Institute (, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research to healthcare to discover which medical procedures, devices, drugs, and processes enable improved patient care. As pioneers in this science for 50 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. Strict conflict-of-interest guidelines ensure objectivity. ECRI Institute is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute PSO is listed as a federally certified Patient Safety Organization by the U.S. Department of Health and Human Services. ECRI Institute convened and operates the Partnership for Health IT Patient Safety, a multi-stakeholder collaborative.

For more information, contact:
Laurie Menyo, Director of Public Relations and Marketing Communications
(610) 825-6000, ext. 5310