Joint Commission to study HIT risks
Measuring harm from HIT key to reducing it
Late in 2011, the Institute of Medicine (IOM) released a report outlining the potential benefits of health information technology, as well as the potential perils associated with it. "Health IT and Patient Safety: Building Safer Systems for Better Care"(available at http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx) included specific recommendations, including that the government should find an independent organization to determine what use of technology could potentially harm patients and how to prevent those scenarios.
Last month, the Office of the National Coordinator (ONC) chose The Joint Commission (TJC) to fulfill that role. Sentinel events related to health IT are reported to the commission on a voluntary basis, which gives TJC some insight into the root causes of various kinds of health IT dangers. The commission will also look at other literature and gather expert opinions to flesh out knowledge of the kind of problems that technology has caused.
Technology-related sentinel events could happen with many types of technology, including hardware — implanted devices and dispensing systems, for instance — or software programs — such as speech recognition or electronic health record systems. Errors in either might result in the wrong medication, wrong dose, wrong treatment, or wrong-site surgery.
TJC will spend about a year studying the potential for error and coming up with possible fixes, says Ron Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission. He says there is no clear idea of how common technology-related sentinel events are or what percentage of overall errors they represent. "All we know is that errors in general are vastly under-reported." The hope is that they will know more by the time the study is complete.
The commission will also develop tools and educational programs to help providers understand the risks, determine ways for providers to more easily report problems, and come up with guidance on how to avoid situations in which sentinel events are possible. "We hope this gives us a better idea of how this kind of event occurs, ways to analyze them, and strategies to use technology while providing safer care," Wyatt says.
Right now, there are multiple systems in most hospitals, and most don't work well together. Wyatt says an example might be a pharmacist who has to work on two different systems. Whenever he or she has to exit one system and move to another, there is the potential for error. Maybe the pharmacist misspells a name in the second system, or misremembers a medication dose or allergy. Such errors can lead to harm.
In early July, Wyatt heard a report of a patient who caught a potentially fatal mistake: the wrong dose of potassium in his drip. "If the nurse had hung the IV bag and delivered the dose, it could have killed him," Wyatt says. It wasn't the nurse's error, but an error made up the line in a computer order. "You can have the best IT systems out there, but there are still human beings using them."
Fatigue, distraction, noise, lighting — these are all things that impact the human beings who deliver medical care, and they are the ones using technology, Wyatt says. "We are hoping to find a way to catch these when they are near misses or precursor events so that they never reach that sentinel event point."
For more information on the ONC contract, contact Ron Wyatt, MD, MHA, Medical Director, Division of Healthcare Improvement, The Joint Commission, Oakbrook Terrace, IL. Telephone: (630) 792-5175. Email: Rwyatt@jointcommission.org.