Garbage in Garbage Out

The Joint Commissionhas (JC) issued a “sentenal alert” for health information technology. A sentenal alert is defined as preventable, unintended injuries or complications resulting in death, disability, or prolonged hospital stay that arise from healthcare management. The Joint Commission is a non-profit watchdog group that sets basic safety standards for our nations hospitals. Since electronic medical records is a standard bearer for Obama’s healthcare reform agenda, I felt it necessary that the public understands that it is not the panacea of quality healthcare.

In a report issued by the JC it says, “… Users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate,” the commission said. “Technology-related adverse events can be associated with all components of a comprehensive technology system and may involve errors of either commission or omission. These unintended adverse events typically stem from human-machine interfaces or organization/system design.” Of the 145,000+ medication errors reported in 2006, of which 1.25% resulted in harm, 43,373, or 25%, involved some aspect of computer technology as at least one cause of the error.

These include, mislabeled barcodes on medications (5 percent), information management systems (2 percent) and unclear or confusing computer screen displays (1.5 percent). The remaining harmful errors were related to dispensing devices, computer software, failure to scan barcodes, computer entry and overrides of barcode warnings. Factors contributing to patient hazard, according to the alert, include poor product selection, insufficient testing or training and over-reliance on vendor advice.  

We (including Tom Raschle and the Obama transition team) must not forget that humans put the data into the machine and humans retrieve the data. Furthermore, it is the patients that provide the data, which may be more often than not, wrong. The Joint Commission lists 13 actions to ensure patient safety and each of these must be implemented before we jump head-long into expensive technology that could leave us worse off than we are now.


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