The Joint Commission released a health IT-related Sentinel Event Alert this spring. There was another one in 2008 related to the convergence of technology regarding electronic health records and devices. Since then, organizations have been informing stakeholders of the concerns they should have and care they should take related to technology that, when used properly, can make the lives of frontline staff easier and the care of patients safer and of higher quality.
This time, the Commission focused on some workflow issues surrounding the various technologies, says Gerry Castro, PhD, project director for patient safety initiatives. “We know that a lot of people are worried about this, but we have the added benefit of the root cause analyses in our database, so we can see how these events transpire, not just the reports of them happening.”
They are finding that harm happens at one end, but the event beginnings are often much further upstream, Castro says. “Someone clicks the wrong thing on the screen, and somewhere further down the road, something bad happens to the patient. The things we have in place to protect patients from that fail, too. There are multiple failures involved.”
These mistakes yield most commonly to medication errors, wrong-site surgeries, and delays in treatment. “And in each one of these cases, there has been significant injury, permanent harm, or death, which is another way our information is different. We aren’t dealing in close calls here. These are the things that actually kill people, hurt people.”
In terms of wrong site surgery, which is one of those events that the general public may not understand, Castro provides an example: A computer terminal is down the hall from the operating theater. There is no way to double-check the right place is being operated on because there has never been an effort to place the new technology that has all the patient information on it in a place where the surgeon can have immediate access for a last check.
Another situation leading to harm Castro relates to is drop-down lists. “How many times have you clicked on the wrong thing in your own life? Or if a scheduler is trying to select something and there is nothing in the list that drops down that fits, you make a decision to pick this next best thing and then write something in the comments. But what if the comments do not get read? What if the provider system does not copy the comments over from the scheduler’s system?”
The goal of these alerts is for hospitals to look at their environments and assess their risks. “You do not necessarily make a connection between this technology that is supposed to make your life easier and a safety issue. And sometimes, these issues just end up on the IT department’s help desk.” That department may not be keyed into patient safety the way others in the hospital are.
“Everyone needs to make the connection between the IT issue and patient safety,” says Castro. He recommends the government SAFER guides, available for a variety of issues related to technology at www.healthit.gov/safer, which offer well-developed checklists and tools that the Office of the National Coordinator for Health Information Technology (ONC) created with a great deal of input from end users and robust research from peer-reviewed literature. “These are a great risk assessment tool, and not just for user issues, but also for organizational and leadership issues, too,” he says.
Those who worked on the alert did learning site visits with organizations to discover which technology they used and how they calculated and moderated the risks related to it, Castro says. This is an issue that will continue to evolve. He mentions smartphones that are used to pull up vital signs for patients, and patient access to Wi-Fi. Both of those offer the potential for data integrity issues at the very least, so chances are there will be another technology-related SEA in the future. “What do you do if all your patients want to stream movies and that makes the hospital bandwidth slow down to the point that it slows down critical information?” he says.
“But what we have seen with many is that they are doing a good job connecting the idea of health IT with the idea of safety,” he says. He can’t name names, but he mentioned the hospital with the smartphones. They keep a bank of them on the unit for use on the unit only. And if they leave the unit, they are programmed to stop working. That means they can’t be removed and used with patients who are not on the unit, nor can the information on the phones be used outside of it. “But I think it will be tough for everyone to keep up.”
The complete alert can be found at http://www.jointcommission.org/assets/1/18/SEA_54.pdf.
For more information on this topic, contact Gerry Castro, Ph.D., Project Director, Patient Safety Issues, Joint Commission, Oakbrook Terrace, IL. Email: [email protected].
