Joint Commission Issues Safety Alert on Health Information Technology

Last week, The Joint Commission, the major regulator and standards-setter for hospitals and other health care providers, issued a "Sentinel Event Alert" on Safely implementing health information and converging technologies. Although the Commission has issued technology alerts before, this one is remarkable in how broad it is, covering the entire domain of HIT and the devices that are attached to the HIT system, including Clinical Decision Support systems.

In it, they noted that 25% of the medication error reports submitted to the US Pharmacopeia involved some kind of computer technology. (It is not clear if this is higher than expected given the prevalence of computerized medication systems in hospitals. Nonetheless, it is a big number.) They also provided a high-level list of 13 suggested actions for implementation and use of HIT that represent a kind of best practices. This list ought to be brought to the attention of everyone involved in these systems - especially the institutional leadership who need to find the funds for these 13 safety steps.

The good news is that Clinical Decision Support was not singled out as a particularly dangerous aspect of HIT (pharmacy took the brunt of the data-driven bad news). Nonetheless, all of us developing Decision Support Systems should keep these issues top-of-mind.