AACE Patient Safety - Editorials

Joint Commission Safety Alert regarding Health Information Technology

On December 11, 2008, the Joint Commission released a sentinel event alert regarding implementation of health information technology (HIT) and converging technologies – the interrelationship between medical devices and information technology.

This very thoughtful document highlights the many ways that poorly designed or implemented HIT products can lead to medical errors and serious problems in patient safety. Although there is much less data on the incidence of adverse events directly caused by HIT, they report data from the United States Pharmacopeia’s MEDMARX database which includes medication error reports, and approximately 25% of the 176,409 medication error records for 2006 involved some aspect of computer technology as at least one cause of the error. Examples included mislabeled barcodes, poorly-designed information management systems and unclear or confusing computer screen displays, but there were many others including those related to computerized physician order entry systems (CPOE) as well.

Unfortunately, often HIT interventions are not done with the inclusion of the front-line clinicians in either the planning or the initial implementation testing, and the results are often disastrous. The Joint Commission report delineates many ways in which the failure to include the front-line clinicians results in errors, which in retrospect, should have been perfectly predictable, given the importance of those at the point of care and the complexity of the work they do.

The Joint Commission has suggested 13 actions to be considered prior to implementing an HIT solution in the health care workplace. These suggestions include the examination of workflow processes prior to any implementation, and improving those processes first instead of relying upon the belief that the HIT solution will “cure all ills”. They stressed the need to test and check what is being proposed, and to take a hard-nosed look as to whether the implementation has improved the processes or merely created new problems, each of which need new solutions.

In summary, the Joint Commission is to be commended for looking beyond the “hype” of information technology solutions and embracing HIT for what it can do to improve health care safety, while recognizing the new problems in patients safety HIT may cause. The Joint Commission suggests general strategies for how to best design and maintain HIT systems to maximize their value and minimize the problems they may bring. HIT is not a panacea for problems in patient safety, it is merely a tool that, if well designed and implemented, can improve patient safety, but at the same time, even the best HIT products present novel challenges and complexities that must not be underestimated if we are to maintain a safe environment for our patients.