Factors potentially leading to

health IT-related sentinel events

Electronic health records (EHRs) can introduce new risks into a complex health care environment in which both technical and social factors must be considered. An analysis of sentinel event reports received by The Joint Commission between January 1, 2010, and June 30, 2013, identified 120 sentinel events that were health IT-related. Factors contributing to

the 120 events were placed into categories corresponding to 8 socio-technical dimensions necessary to

consider for safe and effective health IT.*

Listed by order of frequency

1

Human-computer interface

Ergonomics and usability issues resulting in data-related errors (33%)

3

Clinical content

Design or data issues relating to clinical content or decision support (23%)

2

Workfl w and communication

Issues relating to health IT support of communication and teamwork (24%)

4

Organizational culture

Internal policies, procedures, beliefs, and practices (6%)

5 People

Training and

failure to follow established processes (6%)

6 Hardware and software

Software design issues and other

hardware/software problems (6%)

7

External factors

Vendor and other external issues (1%)

System measurement 8

and monitoring

Issues related to patient safety event reporting, data collection,

and analysis (1%)

*The Joint Commission. Safe use of health information technology. Sentinel Event Alert. Mar 31, 2015. Accessed Mar 31, 2015. http://www.jointcommission.org/daily_update/joint_commission_daily_update.aspx?k=721&b=&t=4.