Joint Commission Alert: Prevent Technology-Related Health Care Errors

(OAKBROOK TERRACE, Ill. - December 11, 2008) Technology is often touted as the "cure" for health care, but a new Joint Commission Sentinel Event Alert [1] issued today warns that implementation of technology and related devices is not a guarantee for success, and may actually jeopardize the quality and safety of patient care.

 The Joint Commission's Alert urges greater attention to understanding when a technology may (or may not) be applicable, choosing the right technology, understanding the impact technology can have on the quality and safety of patient care and attempting to quickly fix technology when it becomes counterproductive. The Alert makes clear that the overall safety and effectiveness of technology in health care ultimately depend on its human users, and that any form of technology can have a negative impact on the quality and safety of care if it is designed or implemented improperly or is misinterpreted.

The Alert notes that there is very little data on the number of errors directly caused by the increasing combined use of health information and devices. As an example, however, root cause analysis of errors shows that computerized medication orders and automated dispensing cabinets for medications are frequently involved. In addition to specific recommendations contained in the Alert, The Joint Commission urges health care organizations to use its Information Management accreditation standards to improve patient safety while using technology. Since technology is so common in health care-from admitting patients to the operating room to ordering and administering medication-any Joint Commission accreditation standard can be tied to technology.

"Innovations in technologies and information systems are vitally important to improve health care quality and safety, but we must be mindful of the safety risks and preventable errors that these implementations can create or perpetuate" says Mark R. Chassin, M.D., M.P.P., M.P.H.., president, The Joint Commission. "The strategies contained in this Alert give organizations and caregivers guidance that can help prevent patient harm and maximize the beneficial impact of these innovations."

The Alert notes that the implementation of technology can threaten care and patient safety when:

• Clinicians and other staff are not included in the planning process;
• Providers do not consider the impact of technology on care processes, workflow and safety;
• Technology is not fixed when it becomes counterproductive; and
• Technology is not updated.

To reduce the risk of errors related to health information and technology, The Joint Commission's Sentinel Event Alert recommends that health care organizations take a series of 13 specific steps, including the following:

• Look for possible risks in how caregivers carry out their work and resolve these issues before putting technology into place;
• Involve the caregivers who will ultimately use the technology;
• Train everyone who will be using the technology and provide frequent refresher courses;
• Make clear who is authorized and responsible for technology-from putting it into use to reviewing safety; and
• Continually seek ways to improve safety and discover errors.Other strategies for reducing technology-related errors include avoiding distractions for staff using technology, monitoring and reporting errors and near misses to find the causes, and protecting the security of information.

Other strategies for reducing technology-related errors include avoiding distractions for staff using technology, monitoring and reporting errors and near misses to find the causes, and protecting the security of information.

The warning about preventing technology-related errors is part of a series of Alerts issued by the Joint Commission. Previous Alerts have addressed anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission website [2].