The Joint Commission studied 120 Sentinel Events, a third of which were related to human-computer interface. Think of a case where you chose the wrong item from a drop-down menu, or if you had two files open and clicked the wrong one. Clinical content was nearly a quarter of them. That relates to design issues related to clinical content, like the ability to have two EHRs open at once. Another quarter were workflow and communication issues. Three issues each had 6%: policies/procedures/culture, people (training or failure to follow the procedures in place), and software or hardware issues.
The Commission recommends three actions related to this alert. First, create a good safety culture in which the issues related to technology are well-known, and when adverse events happen they are reported and investigated. The issue is not about assigning blame, but sharing responsibility.
Second, develop a good process improvement program related to health IT. They recommend the SAFER guides which can be found at http://www.healthit.gov/safer.
Third, have a good leadership culture on this topic, while also engaging people from the frontline staff to help identify risks and come up with solutions and rewarding vendors that have safety in mind when creating their products.
Several requirements from the survey manual relate to this topic. Those related to hospitals are:
IM.01.01.01 (IM.1.10 for some programs)
IM.01.01.03 (IM.2.30 for some programs)
IM.02.01.03 (IM.2.20 for some programs)
LD.04.04.03 (LD.4.20 for some programs)
The complete alert can be found at http://www.jointcommission.org/assets/1/18/SEA_54.pdf.