It is hard to imagine health information technology as a potential safety hazard, but The Joint Commission is pointing out some of the ways hospitals and health care organizations should reconsider the potential risk to patients as a result of health information technology (HIT).
The commission released a Sentinel Event Alert on March 31 that looks at issues that might be of concern, as well as potential solutions to those problems.
According to the alert, there have been 120 reported sentinel events between January 1, 2010, and June 30, 2013, including situations such as a patient being given the wrong mediation because a drug name was autopopulated by the computer system. Another event involved a child whose weight was entered as 34, but the pharmacist did not know if it was pounds or kilograms and the computer system did not indicate age. Medication dosing was again a factor.
The largest share of the problems are caused by human computer interface — 33%, according to the alert. Only 6% can be blamed on software or hardware. A quarter come down to communication.
The Joint Commission suggests several ways to mitigate risk, including the following:
- Identify and report health IT-related hazardous conditions, close calls or instances in which no harm has occurred.
- If a patient is harmed, involve IT staff members and vendors in the comprehensive systematic analysis of the adverse event.
- To the extent possible, make health IT safe and free from malfunctions. This includes making sure new technology is properly installed and tested, and proper training is provided to make sure technology is used safely.
- Health IT should be used to monitor and improve safety.
- Organization leadership should be fully committed to safe health IT, providing oversight to planning, implementation and evaluation.
The sentinel event alert is available at http://www.jointcommission.org/assets/1/18/SEA_54.pdf.
The Joint Commission is offering a free continuing education course, “Investigating and Preventing Health Information Technology-Related Patient Safety Events,” that teaches how to identify, report, and address health IT-related safety concerns in a health care organization. More information is available at The Joint Commission website, www.jointcommission.org.