JC issues alert regarding health IT

The Joint Commission issued a sentinel event alert about the inherent risks of EHRs and other health IT that could harm patients.

Citing the 120 health IT-related events reported by participating hospitals between Jan. 1, 2010, and June 30, 2013, the Joint Commission named confusing human-computer interfaces, poor health IT support and design issues that lead to miscommunication among many concerns cited in the alert. One-third of the errors had to do with human-computer interface usability issues, 24% percent were related to health IT support communication and 23 percent resulted from design or data issues relating to clinical content.

The alert includes examples such as a chest X-ray being mistakenly ordered and performed for the wrong patient when the incorrect room number was clicked, and a physician accidentally choosing the wrong method of injection from a drop-down menu.

EHRs play an increasingly critical role in the healthcare but they “introduce new kinds of risks into an already complex healthcare environment where both technical and social factors must be considered,” according to the alert.

The Joint Commission offered several recommendations, including limiting the number of patient records that can be displayed on the same computer at one time and a comprehensive systematic analysis of each adverse event to determine whether health IT contributed to the problem.

While EHRs can improve healthcare quality and safety through their ability to access important medical history data, provide clinical-decision support tools and facilitate communication among providers, the Joint Commission said “the potential for health IT-related harm will likely increase unless risk-reducing measures are put into place."

Read the alert.