Sentinel Event Alert #42
Safely Implementing Health Information and Converging Technologies
This Sentinel Event Alert issued by The Joint Commission on December 11, 2008, warns that implementation of technology and related devices is not a guarantee for success, and may actually jeopardize the quality and safety of patient care.
The Joint Commission’s Alert urges greater attention to understanding when a technology may (or may not) be applicable, choosing the right technology, understanding the impact technology can have on the quality and safety of patient care, and attempting to quickly fix technology when it becomes counterproductive. The Alert makes clear that the overall safety and effectiveness of technology in health care ultimately depends on its human users, and that any form of technology can have a negative impact on the quality and safety of care if it is designed or implemented improperly or is misinterpreted.
Joint Commission Resources has the following tools to help educate your organization on this very important topic.
Publications
Using Technology to Improve Medication Safety
This book discusses the implementation and integration of technological solutions that provide staff with ways to improve communication and, in turn, improve medication safety.
The Pharmacist's Role in Patient Safety
This book discusses how pharmacists can improve patient safety by implementing technology that helps prevent errors.
The Nurse's Role in Medication Safety
Learn how nurses can use technology to improve patient safety and prevent errors.
Listen-on-Demand Audio Conferences
Use of Technology in Hand-off Communications
Learn how Provena Saint Joseph Medical Center in Joliet, Illinois implemented hand-off communication technology to manage hand-offs hospital-wide.
Use of Technology for Medication Safety
Learn how improved technology can reduce the risk of medication error and help health care organizations continue to meet the highest standards for quality and patient safety.
Web-Based Education/DVDs
Patient Safety on the Line: Using Technology to Aid Effective Communication Among Caregivers
This program emphasizes the importance of timely and effective communication, The Joint Commission's expectations related to communication and technology, and the planning and development it takes to use communication technologies appropriately. Available as a DVD and online.
Articles
E-mergency Management: A Model Plan for Continuing Patient Care During Computer/Communication System Failures
Implementing Computerized Physician Order Management at a Community Hospital
Technology: PET/CT and Patient Safety
Maximizing the Benefits of CPOE Technology
Health Information Technology's Role in Patient Care
Using the e-SOC to Help Manage Your Building: Embracing Technology Makes Facilities Management Run Smoothly
Reviving and Managing Your Contingency Plans: Being Prepared for Equipment, Utilities, and Emergency-related Failure or Disruption
When Medication-related Technology Doesn't Work Correctly
Reducing the Risk of Errors Involving Digital Imaging
Maximizing the Benefits of Smart Pump Technology: Addressing Potential Errors Proactively