Electronic health records introduce new kinds of risks into an already complex healthcare environment, according to a new Sentinel Event Alert published this week by the Joint Commission.
The alert addresses several socio-technical factors at work with health IT that could lead to sentinel events, including usability issues leading to data-related errors; workflow and communication issues; internal/organizational policies; and hardware/software problems, among others.
To that end, suggested actions should focus on three areas, according to the Joint Commission:
- Safety culture: Efforts should include creation of an organization-wide "collective mindfulness" focused on identifying, reporting, analyzing and reducing health IT-related hazardous conditions, close calls or errors; comprehensive systematic analysis of each adverse event causing patient harm to determine whether health IT played a role; and shared involvement and responsibility for the safety of health IT.
- Process improvement: It involves development of a proactive, methodical approach that includes assessing patient safety risks; ensuring health IT hardware and software are safe and free from malfunctions and that they're used in safe and appropriate ways; and using IT to monitor and improve safety.
- Leadership: It calls for enlisting multidisciplinary representation and support; examining workflow processes and procedures for risks and inefficiencies to be resolved before any technology implementation; involving frontline health IT users in system planning and design; and making modifications to the health IT system in a controlled manner.
The alert points organizations to Joint Commission standards on the safe use of health IT.
An evaluation of the graphical displays of lab test results in eight EHRs found they don't do a good job of creating accurate and clear graphs of patient information, which may adversely affect patient safety, according to a new article in the Journal of the American Medical Informatics Association (JAMIA).
Meanwhile, an editorial at BMJ Quality and Safety, states EHRs have not made as much progress in patient safety as the industry had hoped, and calls for collaborative research in a "reinvigorated" need for improvement.