As healthcare information technology (IT) adoption spreads and becomes a critical component of organizational infrastructure, the potential for health IT–related harm will likely increase unless risk-reducing measures are put into place, warns a March 31, 2015, Joint Commission Sentinel Event Alert. According to the Joint Commission and data obtained by the agency from ECRI Institute, incorrect or miscommunicated information entered into health IT systems may result in adverse events, and in some cases, interfaces built into the systems themselves may contribute to the events. An analysis of 120 health IT–related sentinel event reports received by the Joint Commission between January 1, 2010, and June 30, 2013, determined that factors contributing to these events were associated with eight socio-technical dimensions: human-computer interface (33%); workflow and communication (24%); clinical content (23%); internal organizational policies, procedures, and culture (6%); people (6%); hardware and software (6%); external factors (1%); and system measurement and monitoring (1%). The Joint Commission suggests that healthcare organizations employ the eight dimensions model as a framework to help create and maintain well-integrated, fully functioning, and safe health IT systems. Other actions suggested by the agency center on the three crucial areas of safety culture, process improvement, and leadership. The recommendations include creating and maintaining an organizational-wide culture of safety, high reliability, and effective change management; developing a proactive, methodical approach to health IT process improvement that includes assessing patient safety risks using the SAFER Guides for electronic health records checklists, failure mode and effects analysis, or a similar method to identify potential system failures before they occur; and enlisting multidisciplinary representation and support in providing leadership and oversight to health IT planning, implementation, and evaluation.

HRC Recommends: In addition to numerous benefits, health IT has been associated with wide-ranging potential for harm. Maximizing benefits while identifying unintended consequences and ensuring safe use is an ongoing imperative for all healthcare organizations. Risk managers should ensure that appropriate individuals are aware of the Joint Commission Sentinel Event Alert and collaborate with stakeholders across multiple disciplines to ensure reporting of health IT-related events and near misses, conduct thorough event analysis and investigation, and identify corrective measures. ECRI Institute is among the organizations promoting multidisciplinary learning from health IT events through the Partnership for Health IT Patient Safety.