The Joint Commission, which accredits hospitals, has just released a Sentinel Event Alert on "Safely implementing health information and converging technologies."

The Alert explains that as health information technology is increasingly used along with medical devices in health care organizations, the safety risks and preventable adverse events should be considered. The Alert says that technology-related events can be errors of omission or commission, and generally derive from "human-machine interfaces or organization/system design."

While the data on adverse events directly caused by health information technology is slight, the Alert reports that according to the information it has collected, about 25 percent of medication error involved an aspect of computer technology. Most of the technology-related errors were due to mislabeled bar codes medications, although other computer-related errors were reported. The Alert offers a breakdown of these computer-related errors. In addition, the Alert reports a survey which says that safety improvements in Automated Dispensing Cabinets are not in line with the increasing popularity of the technology.
The Alert discusses contributing factors to the problem, including poor product selection, insufficient testing or training, and over-reliance on vendor advice. In addition, the workflow in an organization can be slowed or complicated, and strain placed on schedules, if new technology systems do not have proper planning and integration into the organization.Patient safety may also be affected when the technology is not promptly fixed or systems are not integrated and updated-leading records to become incomplete or inconsistent.

With regard to existing Joint Commission requirements, the Alert lists the existing standards that organizations should pay attention to for patient safety and technology. Finally, the Joint Commission offers several comprehensive suggested actions, including to continuously monitor for problems and quickly address issues during the introduction of new technology, to examine workflow processes and procedures for risks and inefficiencies and resolve issues prior to any technology implementation, and to actively involve clinicians and staff who will ultimately use or be affected by the technology in the planning, selection, design, reassessment and ongoing quality improvement of technology solutions.

The full alert may be found at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

Read the AAMI statement:
http://aami.org/news/2008/121108.jcalert42.html

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