Accreditation Alert: The Joint Commission is tapped to delve into IT-related adverse health events

The Joint Commission is tapped to delve into IT-related adverse health events

With rapid deployment of health information technology proceeding throughout the health care system, the Office of the National Coordinator (ONC) for Health Information Technology has signaled that it wants a stronger arsenal at its disposal to head off the potential for IT-related adverse events. Following up on a recommendation from the Institute of Medicine, the ONC has asked The Joint Commission (TJC) to develop a process that can be used to both identify and prevent health IT-related sentinel events that have the potential to harm patients. According to TJC, the results of this work will inform ONC’s "Health IT Patient Safety Action and Surveillance Plan."

Health IT is integrated into so many aspects of health care these days that the work will also involve identifying high priority areas as well as a means for classifying events, according to TJC. As part of its work, the accrediting agency reports that it plans to develop tools, materials, and resources to help health care providers identify, report, correct, and avoid health IT-related sentinel events.

Raj Ratwani, PhD, the scientific director for the National Center for Human Factors Engineering in Healthcare in Washington, DC, suggests that TJC needs to take a comprehensive look at the way electronic medical records (EMR) are being used and deployed. "There are tremendous workflow issues and there are no easy solutions," he says. "Physicians and the entire medical community continue to pay a heavy cost."

Patient identification errors can be particularly problematic when using EMRs, says Ratwani. This type of error can occur when a clerk or a provider is looking at a list of patients and accidentally clicks on the wrong individual. "When you do that, any order or lab tests that go out into the system are now going to go to a patient you believe is someone else," he says. "The way EMRs are structured can sometimes facilitate that type of error. Selecting a patient from a list is not always easy to do because of how close the names are to each other within the physical interface."

Another issue, especially in busy clinical areas such as the ED, is that there are many distractions and providers are frequently interrupted, notes Ratwani. "Many EMR systems are not taking these factors into consideration," he says. "If you select a patient that was not intended and you haven’t realized it yet, there are not great safety mechanisms to prevent that error from going throughout the system."

Hospitals are employing safety processes to prevent this type of error, such as requiring physicians to double and triple check names, and to have other staff members check the names, explains Ratwani. "Some of these mechanisms can certainly help, but ultimately what they do is increase the work of the clinician in an already busy environment," he says. "You want the software product to fit the needs of the human user. You don’t want the human user to have to adjust their workflow to fit the product, and that is what we are seeing in some of these cases, and that needs to change."

Steven Witz, PhD, MPH, director of the Regenstrief Center for Healthcare Engineering at Purdue University in West Lafayette, IN, is concerned about practitioners becoming too accustomed to health IT when making clinical judgments. "When information systems and technology really start to become highly reliable, it seems as if there is almost a practitioner view of reliance on that system rather than reliance on the system being redundant or a backup to good human practice," he says. "I think that is something that could ultimately be problematic."