Sentinel Event Alert Issued

The Joint Commission Issued an Important Sentinel Event Alert Yesterday.

The safe use of information technology and electronic health records (EHRs) is the focus of a new Sentinel Event Alert (SEA) issued today by The Joint Commission (TJC). TJC analyzed 3,375 sentinel events from January 2, 2010 through June 30, 2013.

120 events had IT-related contributing factors and these were placed into eight categories:

  1. Human-computer interface (33 percent) – ergonomics and usability issues resulting in data-related errors
  2. Workflow and communication (24 percent) – issues relating to EHR support of communication and teamwork
  3. Clinical content (23 percent) – design or data issues relating to clinical content or decision support
  4. Internal organizational policies, procedures and culture (6 percent)
  5. People (6 percent) – training and failure to follow established processes
  6. Hardware and software (6 percent) – software design issues and other hardware/software problems
  7. External factors (1 percent) – vendor and other external issues
  8. System measurement and monitoring (1 percent)

The Sentinel Event Alert contains three major recommendations:

First, create a culture of safety, high reliability and effective change management. TJC lists specific steps for this step including:

  • Identify, report, and analyze hazardous situations, close calls (good catches), and errors, and
  • Perform a systematic analysis of each adverse error that caused patient harm.

I would also recommend performing a cause and effect analysis on all errors to identify common themes that can be addressed.

Second, implement a proactive approach to EHR process improvement using SAFER Guides for EHRs checklists and Failure Mode and Effects Analysis, or a similar method.

Third, enlist multidisciplinary representation and support to provide leadership and oversight for IT planning, implementation, and post go-live evaluation.

The take away for me was succinctly stated by Mark R. Chassin, M.D., president and CEO, The Joint Commission: “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. When all people within a health care organization focus on identifying potential hazards as part of their daily work, then patient safety wins.”

Read the entire Sentinel Event Alert #54

Download a Safety Health IT Infographic produced by TJC 

Sentinel Event Alert #42 – Safely implementing health information and converging technologies