Joint Commission Warns Of HIT Risks

By Christine Kern, contributing writer

The Joint Commission warns of the increasing potential of health-IT related harm to patients.

An alert issued by the Joint Commission warns the rapid evolution and proliferation of HIT brings new challenges and carries with it the potential for increasing HIT-related harm or even death for patients. Sentinel Alert #5: Safe Use of Health Information Technology builds upon Sentinel Event Alert #42, published in 2008, concerning the safe implementation of health information and converging technologies.

The Joint Commission identifies specific types of sentinel and adverse events, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Among the inherent risks of HIT, the alert lists “incorrect or miscommunicated information entered into HIT systems” and “interfaces built into the technology” as contributing to adverse events, which “may occur through the use of electronic health records and related technologies.”

The Commission suggests that, while data integrity and security are crucial to the success of modern healthcare facilities and the well-being of patients, many healthcare organizations have not yet mastered this challenge, according to the AAMI Foundation. “Data integrity may be compromised (mismatched, wrong, missing, or delayed data) due to human-computer interface issues, communication errors, hardware or software issues, or other dimensions,” the alert says.

Further, despite the benefits of using EHRs to reduce adverse events, the alert points out EHRs have had mixed results in detecting and preventing errors. Further, the alert asserts, EHRs “introduce new kinds of risks into an already complex healthcare environment where both technical and social factors must be considered.”

In an analysis of 3,375 sentinel events between January 1, 2010 and June 30, 2013, the Commission identified 120 which caused patient harm or death that were health related. The study further identified eight socio-technical factors (in order of frequency) determined to have contributed to these events:

• Human-computer interface (33 percent) – ergonomics and usability issues resulting in data-related errors,
• workflow and communication (24 percent) – issues relating to HIT support of communication and teamwork,
• clinical content (23 percent) – design or data issues relating to clinical content or decision support ,
• internal organizational policies, procedures and culture (6 percent) ,
• people (6 percent) – training and failure to follow established processes,
• hardware and software (6 percent) – software design issues and other hardware/software problems,
• external factors (1 percent) – vendor and other external issues, and
• system measurement and monitoring (1 percent).

The alert also recommends a set of actions which would help improve the outlook for the safe use of EHRs and HIT. First, the Commission urges the creation of an organizational-wide safety culture, including collective mindfulness of safety issues, comprehensive systematic analysis of adverse events, and shared involvement and responsibility for the safety of HIT across the organization.

Second, healthcare organizations should “develop a proactive methodical approach to HIT process improvement that includes assessing patient safety risks.” They recommend using the Safer Guides for EHRs checklists, Failure Mode and Effects Analysis, or other methods to proactively forestall potential problems.

And finally, the Commission identifies leadership as crucial to ensuring patient safety in the context of implementing EHRs. The alert recommends enlisting “multidisciplinary representation and support in providing leadership and oversight to HIT planning, implementation and evaluation.”

When it comes to leadership, the alert advises enlisting “multidisciplinary representation and support in providing leadership and oversight to HIT planning, implementation and evaluation.”