A new Joint Commission Sentinel Event Alert Thursday issued a warning that the implementation of technology and related devices is not a guarantee for success of healthcare, and may actually jeopardize the quality and safety of patient care.
The commission’s Alert urged “greater attention to understanding when a technology may (or may not) be applicable, choosing the right technology, understanding the impact technology can have on the quality and safety of patient care and attempting to quickly fix technology when it becomes counterproductive.” The Alert stated that the overall safety and effectiveness of healthcare IT depends on its human users and technology can have a negative impact on the quality and safety of care, if it is designed or implemented improperly or is misinterpreted.
The Alert noted that there is “very little data on the number of errors directly caused by the increasing combined use of health information and devices. As an example, however, root cause analysis of errors shows that computerized medication orders and automated dispensing cabinets for medications are frequently involved, according to the commission.
The Alert said that the implementation of technology can threaten care and patient safety when:
- Clinicians and other staff are not included in the planning process;
- Providers do not consider the impact of technology on care processes, workflow and safety;
- Technology is not fixed when it becomes counterproductive; and
- Technology is not updated.
To reduce the risk of errors related to health IT, the commission’s Alert recommended that healthcare organizations take a series of 13 specific steps, including:
- Look for possible risks in how caregivers carry out their work and resolve the issues before putting technology into place;
- Involve the caregivers who will ultimately use the technology;
- Train everyone who will use the technology and provide refresher courses;
- Make clear who is authorized and responsible for technology—from putting it into use to reviewing safety; and
- Continually seek ways to improve safety and discover errors.
Other strategies for reducing technology-related errors include avoiding distractions for staff using technology, monitoring and reporting errors and near misses to find the causes, and protecting the security of information, according to the commission.
In addition to recommendations contained in the Alert, the commission urged healthcare organizations to use its Information Management accreditation standards to improve patient safety while using technology. “Since technology is so common in healthcare—from admitting patients to the operating room to ordering and administering medication—any Joint Commission accreditation standard can be tied to technology,” the commission said.
The Joint Commission said that this warning about preventing technology-related errors is part of a series of alerts.