Sentinel Alert For Health Technology

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Sentinel Alert For Health Technology

The Joint Commission has concerns about digital tools

By Working Nurse
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Most nurses today have strong feelings about electronic health record systems and other digital tools, which can create as many headaches as solutions. Now, The Joint Commission has issued a new Sentinel Event Alert regarding health technology problems that impact patient safety.

Usability Difficulties

According to the new alert, issued March 31, health IT issues were a contributing factor in 120 of the sentinel events (adverse events resulting in patient death or permanent harm) that The Joint Commission reviewed between Jan. 1, 2010, and June 30, 2013.

Fully one-third of the technology-related issues involved data-entry errors (such as ordering the wrong medication or procedures), many of them resulting from usability issues. Other frequent contributing factors included problems with integrating  digital systems into staff communications, procedures and workflow.

Room for Improvement  

The new alert offers various recommendations for improving safety, including involving both staff and technology vendors in the investigation of any adverse events. Procedures should be established for identifying and addressing hazardous conditions and “close calls” that don’t result in actual harm.

Mark R. Chassin, M.D., FACP, MPP, MPH, The Joint Commission’s president and CEO, says the potential hazards health IT has created “can be averted through strong organizational leadership that emphasizes a culture of safety and continuous process improvement.”

Free Online Course

If you’re interested in learning more, The Joint Commission is offering a new online course entitled “Safe Health IT Saves Lives.” The course is free and provides one hour of continuing education credit. Click here for more information.

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