A recent Joint Commission sentinel event alert that warned health IT can pose risks to patients has received mixed reaction from stakeholders, Health Data Management reports (Slabodkin, Health Data Management, 4/22).
Background
The alert — which was issued last month — stated that EHRs “introduce new kinds of risks into an already complex health care environment where both technical and social factors must be considered.”
The alert cited an analysis of event reports received by the Joint Commission showing that between Jan. 1, 2010, and June 30, 2013, hospitals reported 120 health IT-related adverse events. Of those errors:
- About 33% stemmed from human-computer interface usability problems;
- 24% stemmed from health IT support communication issues; and
- 23% stemmed from clinical content-related design or data issues.
The alert recommended:
- Implementing comprehensive systematic analysis of all adverse events to determine whether they were the result of health IT issues; and
- Limiting the number of patient records that can be displayed on the same screen at once (iHealthBeat, 4/1).
Comments
In interviews with Health Data Management, some stakeholders said they supported the alert for highlighting errors that can cause harm and creating a “baseline” for future analysis, while others questioned the scope of the Joint Commission’s analysis.
Andrew Gettinger — CMIO of the Office of the National Coordinator for Health IT and acting director of the Office of Clinical Quality and Safety — said that what “we now know from this study and other studies … [is] that on average health IT makes patient care much safer.” He noted that “there are small incidents — that get a lot of attention — where health IT has created new safety signals for us.”
According to Gettinger, such small errors are regularly identified in the industry.
He said that it is “important to distinguish really meaningful errors that can create harms,” noting that “health IT, if appropriately configured with attention to these things, can prevent a lot of those downstream things.”
Robert Wachter, a professor at the University of California-San Francisco’s Department of Medicine, noted that the sheer volume of alerts physicians receive can result in patient harm, noting that if a computer is issuing thousands of alerts, “normal people begin to tune [them] out.”
Meanwhile, Annie Callanan, CEO of software vendor Quantros, said, “We cannot rely on 120 events when some reporting systems have more than 40 million events in their repositories to draw from.” Instead, she said that “we have to go to the heart of where the data reside and really look at what the trends are, what the problems are and better report on them.”
Callanan also criticized the alert for listing human error as the top reason for sentinel events.
She said the top reason actually is “a lack of system compatibility and multiple electronic systems not talking to one another” (Health Data Management, 4/22).
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