Latest sentinel event alert focuses on technology-related errors
Latest sentinel event alert focuses on technology-related errors
Recommendations for making technology work for you
The Joint Commission's latest sentinel event alert urges caution and foresight in dealing with the safety risks and preventable adverse events associated with technology-related errors, "as health information technology (HIT) and 'converging technologies' — the interrelationship between medical devices and HIT — are increasingly adopted by health care organizations."
According to the alert, the MEDMARX database from the U.S. Pharmacopeia includes more than 176,409 medication errors for 2006. Of those, about 25% of those involved computer technology as at least one cause. "Most of the harmful technology-related errors involved mislabeled barcodes on medications (5%), information management systems (2%), and unclear or confusing computer screen displays (1.5%). The remaining harmful errors were related to dispensing devices, computer software, failure to scan barcodes, computer entry (other than CPOE), CPOE, and overrides of barcode warnings."
In its suggested actions, The Joint Commission stresses careful analysis of workflow processes before and after implementation, not over-relying on vendor advice, involving clinicians in the introduction and implementation of technology systems, and assessing your needs prior to buying the technology. (See the sentinel event alert in its entirety at www.jointcommission.org/SentinelEvents.)
Robert Wise, MD, vice president of standards and survey methods at The Joint Commission, urges hospitals not to shy away from technology use. "I think the message here is that technology is an important part of delivering care now, and it will continue to be an important part, but the implementation of it, if not done in a careful way in both the planning, the implementation, and the follow up can end up having unanticipated consequences, which can produce a number of quality and safety issues."
One of the major problems he sees is where the health care industry is in the evolution of technology systems. For instance, the electronic medical record has been a subject of conversation for 30 to 40 years, and it continues to evolve to this day. "At the same time," he adds, "there are lots of other technologies that all speak to each other. So the problem is that the whole industry is being put together in a piecemeal fashion, where the pieces don't fit together very well."
The issue of converging all of these interfaces has never been resolved. "There's no evidence on the horizon that that's going to get fixed any time soon. So for a significant period of time, there will continue to be inherent problems integrating new technology into existing technology. So to wait until that problem is fixed is to deprive the industry of important technology."
Further emphasizing the need for health informatics, Wise points to the data-rich environment of health care. "We're being flooded with data. There's no way you can possibly handle the data any longer, either to understand it internally or to move it as it needs to be moved, without the use of technology."
It's not technology's fault
In this vein, Wise says, many times technology is faulted for "problems," when the error is actually a result of poor implementation, perhaps because those who needed to be at the table were not or training on the system was inadequate. If every time technology fails, staff response is "'the technology wasn't good enough,' you're missing some of the broader issues of what it takes to implement something," he says.
If every hospital was able to wipe its existing technology away and everyone could start on the same platform, Wise says, "it would obviously be a lot easier." But the legacy systems throughout health care are going to remain for a long time, he says.
Human interaction with human informatics is ripe for potential problems. "One of the things that computers do very well is that they do the same thing over and over and over again." If the wrong dose is put into an automatic dispensing machine by human input, every time that medication is ordered, the machine will give the wrong dose. "Again, I think just because technology is in the loop does not necessarily point to the technology. Very often it points to the improper understanding of the work flow — not doing the training properly, not having the proper checks," Wise says.
Joint Commission recommendations
Pointing to The Joint Commission recommendations in the sentinel event alert, "most of it's not about the technology," Wise says. "It's about the integration of it, examining your work flow processes." And perhaps most important, he says, is assessing your need, the reason you're installing the specific technology at hand before you purchase the system.
"A lot of times people buy the technology because it's really nifty, but the question is: Does it solve the problem the organization needs? So if the technology is bought and then you try to impose it upon an organization, you already have a problem. The first question is what is the problem you're trying to solve, and then you buy the technology. The number of times that's done backwards is pretty significant."
As with any quality improvement process, you need to get all the right players at the table and let staff know initially employing technology will take more time as they learn the system. If you impose a system without this, "I guarantee you're going to have a failure," Wise says.
And post-implementation, as with any QA project, you must constantly look for instances in which the systems aren't doing or giving you what you need. Constant surveillance and learning from near misses is essential.
The Joint Commission's latest sentinel event alert urges caution and foresight in dealing with the safety risks and preventable adverse events associated with technology-related errors, "as health information technology (HIT) and 'converging technologies' the interrelationship between medical devices and HIT are increasingly adopted by health care organizations."Subscribe Now for Access
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