Joint Commission warns of IT hazards

The Joint Commission has released a Sentinel Event Alert examining the relationship between health information technology (IT) and patient safety.

After analyzing 3,375 sentinel events resulting in permanent harm or death from Jan. 1, 2010, to June 30, 2013, the Joint Commission found that 120 events had health IT contributing factors. As a result, the Joint Commission suggests the following:

• 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.
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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.

"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, FACP, MPP, MPH, president and CEO of the Joint Commission, in a press release. "When all people within a healthcare organization focus on identifying potential hazards as part of their daily work, then patient safety wins."