Joint Commission Issues Alert About Potential Health IT Risks

High risk magnifying glass

The Joint Commission issued a sentinel event alert warning that while electronic health records and other health IT have the potential to improve care quality and safety, such technologies can pose inherent risks to patients, Modern Healthcare reports.

Details of Alert

According to the alert -- which builds upon a 2008 notice that focused on safely implementing health IT and converging technologies -- concerns about health IT include:

  • Complex human-computer interfaces;
  • Design issues that result in miscommunication; and
  • Poor health IT support.

It stated that EHRs "introduce new kinds of risks into an already complex health care environment where both technical and social factors must be considered" (Rice, Modern Healthcare, 3/31).

The alert cited an analysis of event reports received by the Joint Commission showing that between Jan. 1, 2010, and June 30, 2013, hospitals reported 120 health IT-related adverse events (Allen et al., "Morning eHealth," Politico, 4/1). Of those errors:

  • About 33% stemmed from human-computer interface usability problems;
  • 24% stemmed from health IT support communication issues; and
  • 23% stemmed from clinical content-related design or data issues (Modern Healthcare, 3/31).

The alert added, "As health 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" ("Morning eHealth," Politico, 4/1).


The Joint Commission said that EHR systems must be well-designed and appropriately used in order to improve outcomes through their ability to:

  • Access data;
  • Provide clinical decision support tools; and
  • Facilitate communication.

Specifically, the alert recommended:

  • Implementing comprehensive systematic analysis of all adverse events to determine whether they were the result of health IT issues; and
  • Limiting the number of patient records that can be displayed on the same screen at once (Modern Healthcare, 3/31).
Source: iHealthBeat, Wednesday, April 1, 2015

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