The alert issued recently by The Joint Commission, citing the risks and socio-technical factors leading to health information technology “sentinel” events, has spawned both supporters and detractors.

On the one hand, the Office of the National Coordinator for Health IT points to the alert as “an objective” finding on the topic of HIT and patient safety that should serve as a “baseline” for future studies. But, critics charge that the alert cites a very limited number of sentinel events reported over a three-year period.

Funded by ONC, the alert identifies specific types of sentinel, adverse events and high-risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. While the alert’s suggested actions center on safety culture, process improvement and leadership, The Joint Commission found that “incorrect or miscommunicated information entered into health IT systems may result in adverse events” and “in some cases, interfaces built into the technology contribute to the events.”

Also See: Inherent Risks of Health IT, EHRs Putting Patients in Peril 

Andrew Gettinger, M.D., ONC’s chief medical information officer and director of the Office of Clinical Quality and Safety, describes the alert as an analysis that “looked to see whether or not there were health IT signals” in The Joint Commission’s sentinel event database.

“The punch line for me is that we now know from this study and other studies, not just the ones that we funded but others on the academic side of this issue, that on average health IT makes patient care much safer,” said Gettinger. “However, there are small incidents—that get a lot of attention—where health IT has created new safety signals for us.”

The Joint Commission analyzed 3,375 sentinel events that resulted in permanent patient harm or death from January 1, 2010, to June 30, 2013. Of that number, 120 events were identified as having health IT-related contributing factors.

“We cannot rely on 120 events when some reporting systems have more than 40 million events in their repositories to draw from,” said Annie Callanan, CEO of Quantros, a quality/safety software and services vendor whose database tracks thousands of hospitals and pharmacies nationwide for adverse events, safety issues and what the company calls near misses. “Some of our systems capture 120 events in an hour in any given day. So, we have to go to the heart of where the data resides and really look at what the trends are, what the problems are, and better report on them.”

For example, a January 2015 article in the journal BMJ Quality and Safety found that while computerized provider order entry (CPOE) systems have “long been considered and demonstrated to be a high-leverage tool for preventing medication errors,” there is a “growing awareness and increasing documentation of concerns that CPOE can also introduce or facilitate new errors.” The article states that between 2003 and 2010 more than 1 million medication errors were reported to the MEDMARX (Quantros) registry of adverse drug events, of which 63,040 were reported as CPOE-related.

“When we talk about health IT safety issues, we’re not talking about one individual making mistakes. We’re talking about a systematic series of things that have to happen in order for a mistake to actually occur,” argues Gettinger. “When you see something in a computer, you typically don’t challenge it. And, so, what we’ve said is that if you are a clinician you shouldn’t lose your clinical sense of ‘trust but verify.’ It’s important to think through—does that sound/look right?—because that’s where we identify some of these errors. Many of them are caught by our colleagues, the pharmacists, before they ever get to a patient.”

But, Robert Wachter, M.D., a professor in the Department of Medicine at the University of California, San Francisco, details a case from his own hospital in which a patient was given a 39-fold overdose of a routine antibiotic that was not caught by a pharmacist. “The way we did that was basically a simple screen error where the doctor didn’t realize that she was prescribing in milligrams of drug per kilogram of weight,” admitted Wachter. “What was fascinating about it was that alerts were fired to warn the doctor—and ultimately then to warn the pharmacist—that this was an error, but they were ignored by everyone. You might ask: how could they be so careless? Well, it turns out we get hundreds of thousands of alerts. If you add in the intensive care unit computer monitors, we actually get millions of alerts a month. And, so, of course normal people begin to tune out.”

According to Gettinger, small errors in health IT are identified regularly. “What I try and explain to folks is that when you put in one of these systems, it’s not a one-time thing,” he cautions. “Once the system is installed you move into what I call the optimization phase, which never goes away, because the software continues to change and get better—and, sometimes it doesn’t get better, it gets a little bit worse. And, then, it gets better again because we identify what was wrong. It’s that focus that requires vigilance and attention.”

Gettinger says that “it’s important to distinguish really meaningful errors that can create harms” and “the sentinel events are things where there was harm, or what they call SNOs—substantial negative outcomes, which is the safety world’s language, not mine.” Nonetheless, he believes that “health IT, if appropriately configured with attention to these things, can prevent a lot of those downstream things.”

However, Callanan criticizes the alert for placing too much blame on human error, rather than system error. Among the eight socio-technical factors cited in the alert for contributing to sentinel events, The Joint Commission lists human-computer interface—ergonomics and usability issues resulting in data-related errors—as the number one factor. But, Callanan asserts that the top health IT-related cause of adverse events is “a lack of system compatibility and multiple electronic systems not talking to one another—and they don’t even talk about that in the alert.”

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