In a recent Sentinel Event Alert, The Joint Commission (TJC) warned of how incorrect or miscommunicated information entered into health IT systems might result in adverse events.

The Alert cited incidents documented by the ECRI Institute in Plymouth Meeting, PA:

• A chest X-ray was ordered for the wrong patient when the wrong patient room number was accidentally clicked. The orderer noticed the error right away and promptly discontinued the order, but not in time for the X-ray technician to see that the order was withdrawn. The technician performed the test on the wrong patient.

• A drug was ordered as an intramuscular injection when it was supposed to be administered intravenously. The physician did not choose the appropriate delivery route from the drop-down menu.

• A nurse noted that a patient had a new order for acetaminophen. After speaking with the pharmacist, the nurse determined that the order was placed for the wrong patient. The pharmacist had two patient records open, was interrupted, and subsequently entered the order for the wrong patient.

TJC recommends an improved safety culture, process improvement, and leadership regarding EHR safety. In particular, the commission urges a “collective mindfulness focused on identifying, reporting, analyzing and reducing health IT-related hazardous conditions, close calls or errors.” Report these instances internally, preferably at early stages, before a patient is harmed, TJC advises. The full Alert, with resources, is available online at

The TJC warning came on the heels of a letter in which representatives from 27 medical societies, including the American Medical Association, the American College of Physicians, the American College of Surgeons, and several other major medical organizations, expressed their worries about EHR safety to the national coordinator for health information at the Department of Health and Human Services.

“Unfortunately, we believe the Meaningful Use (MU) certification requirements are contributing to EHR system problems, and we are worried about the downstream effects on patient safety,” they wrote. “Physician informaticists and vendors have reported to us that MU certification has become the priority in health information technology (health IT) design at the expense of meeting physician customers’ needs, patient safety, and product innovation. We are also concerned with the lack of oversight ONC places on authorized testing and certification bodies (ATCB) for ensuring testing procedures and standards are adequate to secure and protect electronic patient information contained in EHRs.” The full letter can be found online at