Joint Commission Inventory of Health IT Mishaps
At the first of 10 webinars on Health IT Safety sponsored by ONC, The Joint Commission presented its findings on Health IT events derives from its Sentinel Events program. The other presenter was the Pennsylvania Patient Safety Authority. The slides, and slides with audio, are available for download. The next webinar in the series is “Health IT and Ambulatory Medication Safety: What is the Role of E-Prescribing?” on January 30, 2015.
What I found most interesting was the diversity of issues attributed to IT problems. These included (in decreasing order of incidence) medication error, wrong site surgery, delay in treatment, suicide, fall, radiation overdose, transfusion error, unintended retention of a foreign body, op/post-op complication, medical equipment related, other unanticipated events, perinatal death/injury, transfer-related event, maternal death, and ventilator death. These events were distributed over eight causative effects. The first, hardware and software, is what would generally be expected in a review of IT issues, but this category only accounted for 6% of the adverse events . Hardware/software is followed by clinical content, user interface; people in general; workflow and communication; organizational policies, procedures, environment and culture; rules, regulations and pressures; and system measurement and monitoring. Of these, user interface (33%) and clinical content (23%) were the largest contributors. Within the clinical content category 39% of issues were software design, and 29% decision support. The latter were missing recommendations or lack of safeguard flagging, illustrating that decision support can be problematical not just when it is wrong or ignored, but also when it doesn’t provide what it is expected to provide. This issue is now a classic in the unintended effects of alarm systems in which false reliance replaces personal vigilance.
The broader list reminds us (if we forgot) that IT does not operate in isolation or even in the background, but instead is increasingly interwoven with the entire patient care process. While it may be tempting, especially for IT types, to assert that the software didn’t do anything wrong, and that therefore a bad outcome cannot be the software’s fault, the broader view is that if the software didn’t give users what they needed, in a manner that is likely to be effective, then the software is part of the system failure. This is what should be the well known human factors perspective of design aspect that connect what theoretically should occur with what actually needs to occur in the real environment of use with real users. In this regard the possible ability of users to overcome the software’s limitations does not over ride an observation that, for example, the software had a design flaw that put important information in an obscure place that was not seen (searched out) when it was needed. Also noted in the presentation was the impact of IT on communications and that data being in there someplace is not the same as effectively communicating that data among caregivers in a timely manner.
Health IT, in all its forms, may mitigate certain types of healthcare errors, but it can also interject new errors or reinforce others. Change is not a simple thing, and active risk management and vigilance remain as essential components for the effective use of Health IT.