While health IT can offer providers a number of benefits, the technology also presents a safety risk in the hospital. The Joint Commission released a new Sentinel Event Alert discussing safe use of health IT.
The Joint Commission analyzed 3,375 sentinel events between Jan. 1, 2010 and June 30, 2013 that resulted in either permanent patient harm or death. Of those sentinel events, 120 resulted from health IT-related contributing factors, which the Joint Commission identifies as socio-technical dimensions.
Here are the eight socio-technical factors. The percentage indicates how many of the 120 health IT-related sentinel events in the review pertained to each factor.
Human-computer interface: 33 percent
Workflow and communication: 24 percent
Clinical content: 23 percent
Internal organizational policies, procedures and culture: 6 percent
People: 6 percent
Hardware and software computing infrastructure: 6 percent
External rules, regulations and pressures: 1 percent
System measurement and monitoring: 1 percent
The alert also outlines steps and actions to boost IT safety and reduce IT-related sentinel events. Clinicians should identify and report health IT-related hazardous conditions even when no harm has occurred, involve IT staff members and vendors in a systematic analysis of an adverse event if a patient is harmed, ensure IT is free of malfunctions by continuously testing technology and training staff, and use health IT to monitor and improve safety.
"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, MD, president and CEO of The Joint Commission. "When all people within a healthcare organization focus on identifying potential hazards as part of their daily work, then patient safety wins."
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