Joint Commission Issues Sentinel Event Alert On EHR Safety Risks

Leadership's Role is Key to Safety, According to Alert

(OAKBROOK TERRACE, Ill. – March 31, 2015) Safe use of health information technology (health IT) is the focus of a new Sentinel Event Alert released today by The Joint Commission. The new alert examines the contributing factors to sentinel events that are health IT-related and includes suggested solutions to be implemented by health care organizations. It builds on Sentinel Event Alert, Issue 42, issued in 2008, which focused on safely implementing health information and converging technologies.

With the rapid evolution of health IT, new challenges are emerging in health care that impact patient safety. In an effort to better understand these challenges, The Joint Commission analyzed 3,375 sentinel events that resulted in permanent patient harm or death from January 1, 2010, to June 30, 2013. Of that group, 120 events were identified as having health IT-related contributing factors. Factors contributing to the 120 events were categorized to eight corresponding socio-technical dimensions listed in the alert.

Health IT risks are attributed to a variety of factors, from the usability of interfaces built into the technology to the associated processes and workflows. Some of the suggested actions in the alert include:

• 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.

Mark R. Chassin, M.D., F.A.C.P., M.P.P., M.P.H., president and CEO, The Joint Commission.“Technology has the potential to produce substantial benefits for health care, but this new alert points to the inherent risks that are also posed by health IT. The alert shows these risks can be averted through strong organizational leadership that emphasizes a culture of safety and continuous process improvement,” said Mark R. Chassin, M.D., F.A.C.P., M.P.P., M.P.H., president and CEO, The Joint Commission. “When all people within a health care organization focus on identifying potential hazards as part of their daily work, then patient safety wins.”

In conjunction with the alert, 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. There is also a corresponding infographic to educate health care workers about health IT issues. The course was developed with funding by the Office of the National Coordinator for Health Information Technology.

For more information about the alert, and the free CE course, please visit The Joint Commission’s Safe Health IT Saves Lives Web page here.

About The Joint Commission

Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at www.jointcommission.org.