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Joint Commission issues warning on EHR safety

EHR errors can cause serious problems.

The Joint Commission, the independent healthcare accreditation agency that functions as a quasi-governmental body, issued that warning in the days before the giant HIMSS 2015 (Healthcare Information Management and Systems Society) event, which is the health IT industry’s biggest conference and exhibition, set for April 12-16 in Chicago.

We don’t know if the timing was intentional.

But the commission’s March 31 Sentinel Event Alert, a statement that healthcare problems exist that may warrant corrective action and make providers subject to added scrutiny from commission surveyors, is a move that most healthcare providers should take seriously, and probably do.

In such alerts, the commission also sets out possible ways to correct problems.

In this case, while the commission explicitly recognizes the beneficial aspects and improvements in medical care that EHR systems have brought, the alert notes that the technology itself can be dangerous at times, and that medical mistakes sometimes are not just products of human error.

“Incorrect or miscommunicated information entered into health IT systems may result in adverse events,” the alert states. “In some cases, interfaces built into the technology contribute to the events.”

The commission flags three anonymized events stemming from such EHR mishaps:

  • A chest X-ray ordered for the wrong person when someone mistakenly checked the wrong box in an EHR
  • A doctor wrongly ordered an intramuscular injection when it was supposed to be done intravenously because the physician failed to choose the correct delivery method from the EHR’s drop-down menu
  • A pharmacist had two patient records open and entered an order for acetaminophen for the wrong patient

“These examples show the risks inherent in health IT, and studies have documented mixed results in EHRs’ ability to detect and prevent errors,” the alert’s authors write.

So, the commission is urging stronger emphasis on creating a safety culture at healthcare providers, improving EHR processes, and building stronger leadership around safety in health IT.

These are eminently useful proposals.

Indeed, instances in which EHRs hurt rather than helped have been flagged at multiple healthcare providers over the years.

And ONC as part of its mission considers health IT safety. I spoke recently with a top ONC official who heads up the agency’s quality and safety group and he told me that EHR safety and usability are inextricably intertwined.The Joint Commission is welcome to join this space.

But considering that the group issued its last Sentinel Event Alert around health IT in 2008 (the commission says this year’s alert builds on the previous one), one has to wonder where the commission has been since then.