As the adoption of health information technology continues to grow industry-wide, the potential for health IT-related harm to patients and even death will increase unless risk-reducing measures are put into place by healthcare organizations.

That’s the dire warning of a new alert from The Joint Commission that identifies specific types of sentinel and adverse events, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. According to the alert, health IT has inherent risks. Specifically, the document cites “incorrect or miscommunicated information entered into health IT systems” and “interfaces built into the technology” as contributing to adverse events, which “may occur through the use of electronic health records and related technologies.”

Also See: Health IT Safety Remains Work in Progress for EHRs

While EHRs have demonstrated the ability to reduce adverse events, the alert references studies showing that EHRs have mixed results in detecting and preventing errors. In addition, the alert claims that EHRs “introduce new kinds of risks into an already complex healthcare environment where both technical and social factors must be considered.”

The Joint Commission in 2008 issued a health IT safety alert and the new one follows up by looking at socio-technical factors affecting safe use, giving three examples: A chest X-ray ordered for the wrong patient when the wrong patient room number was clicked, a drug ordered as an intramuscular injection when it should have been intravenously administered, and acetaminophen ordered for the wrong patient because a pharmacist had two patient records open at the time and was interrupted.

The 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. The eight socio-technical factors (in order of frequency) determined to have contributed to these events are:

*Human-computer interface (33 percent) – ergonomics and usability issues resulting in data-related errors,

*Workflow and communication (24 percent) – issues relating to health IT support of communication and teamwork,

*Clinical content (23 percent) – design or data issues relating to clinical content or decision support ,

*Internal organizational policies, procedures and culture (6 percent) ,

*People (6 percent) – training and failure to follow established processes,

*Hardware and software (6 percent) – software design issues and other hardware/software problems,

*External factors (1 percent) – vendor and other external issues, and

*System measurement and monitoring (1 percent).

The alert suggests actions to be implemented by health care organizations focused on three areas: safety culture, process improvement and leadership. The Joint Commission recommends creating and maintaining “an organizational-wide culture of safety, high reliability and effective change management” and developing a “proactive, methodical approach to health IT process improvement that includes assessing patient safety risks.”

When it comes to leadership, the alert advises enlisting “multidisciplinary representation and support in providing leadership and oversight to health IT planning, implementation and evaluation.” 


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