Technology used wrongly harms patients, Joint Commission warns

Hospitals should consult physicians to ensure that new equipment is properly integrated into clinical work flow to avoid unintended consequences.

By Kevin B. O’Reilly — Posted Jan. 15, 2009

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The Joint Commission has confirmed what many physicians have long suspected: For all the hope that gee-whiz technology can improve quality and safety, even the smartest machines can lead to medical errors.

The commission, which accredits hospitals and other health care organizations, warned in a December 2008 sentinel event alert that "not only must the technology or device be designed to be safe, it must also be operated safely within a safe work flow process."

At least 10% of harmful medication mistakes are technology-related failures, according to U.S. Pharmacopeia's Medmarx voluntary drug error-reporting database. Everything from barcodes that fail to scan to confusing computer screen displays were to blame, USP's 2008 report said.

Other studies have found that computerized physician order entry systems facilitate 22 different types of medical mistakes, while nurses frequently skip scanning barcodes to work around poorly implemented systems.

"Computers don't make us less stupid," said Joint Commission President Mark Chassin, MD, MPH, in a news conference. "They make us stupid faster."

The commission's alert said hospitals should not rely solely on vendors to help implement technology, whether it is a CPOE or automated medication dispensing cabinet. Hospital information technology departments should solicit the input of physicians and other health professionals before putting new technology in place.

Dr. Chassin said new tech processes can have unintended consequences, such as inadvertently cutting out a safety check that existed on paper but is not part of a new computerized system. For example, because computerized medication orders go straight from the physician to the pharmacy, fewer eyes see the order, leaving fewer chances to catch a mistake.

Peter B. Angood, MD, said hospitals need to ensure new technologies go hand-in-hand with clinician work flow.

"When considering a use for new technology, look critically at how you're doing the work already," said Dr. Angood, the commission's chief patient safety officer. "Identify what the problems are, and don't be naive about thinking technology will solve everything."

The commission previously warned hospitals about potential adverse events associated with specific devices, such as infusion pumps, ventilators, patient-controlled analgesia, tubing misconnections and magnetic resonance imaging machines. The organization defines a sentinel event as "any process variation for which a recurrence would carry a significant chance of a serious adverse outcome."

The Joint Commission's alert is available online (link).

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