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Joint Commission warns of computer-related safety risks

Hospitalist Leadership Connection, December 16, 2008

Healthcare organizations should be cautious when using computer-related technologies as the use may be linked to harmful medical errors, according to The Joint Commission’s Sentinel Event Alert last week. As a resource for health information management and converging health technology, Sentinel Event Alert warned of some associated safety risks.

In 2006, nearly a quarter of all medication errors were associated with computer technology as at least one of the causes of the error, according to the United States Pharmacopeia MEDMARX database. Other computer-related harmful errors included barcodes or mislabeled medication (5%), the information management system (2%), an unclear or confusing computer screen (1.5%), dispensing device (1.3%), barcode scan failure (less than 1%), computer entry other than computer physician order entry (CPOE) (less than 1%), and CPOE (less than 1%).

“The overall safety and effectiveness of technology in healthcare ultimately depend on its human users, ideally working in close concert with properly designed and installed electronic systems,” stated the Dec. 11 issue of The Joint Commission Sentinel Event Alert.

The Joint Commission suggests steps to safely use computer-related technology, including the following:

• Look at clinical, clerical, and/or technical workflow process
• Involve clinicians in quality improvement of technology solutions
• Assess your organization’s technological needs, including investigating possible conflicting interfaces between system vendors
• Monitor new technology for initial problems
• Train clinicians and operations staff
• Develop and communicate policies, designating responsible parties for use and safety review
• Reassess HIPAA compliance

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