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The Contribution of Sociotechnical Factors to Health Information Technology-Related Sentinel Events.
Jt Comm J Qual Patient Saf ; 42(2): 70-6, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26803035


An understanding of how health information technology (health IT) can contribute to sentinel events is necessary to learn how to safely implement and use health IT. An analysis was conducted to explore how health IT may contribute to adverse events that result in death or severe harm to the patient.


For 3,375 de-identified sentinel events voluntarily reported to The Joint Commission between January 1, 2010, and June 30, 2013, categorical and keyword queries were used to search for potential health IT-related events. Each of the identified events was reviewed on the basis of findings from root cause analyses (RCAs) to determine if health IT contributed to or caused the event, and if so, how and why. The contributing factors were classified using a composite of existing classification schemes.


A total of 120 health IT-related sentinel events (affecting 125 patients) were identified. More than half resulted in patient death, 30% resulted in unexpected or additional care, and 11% resulted in permanent loss of function. The three most frequently identified event types were (1) medication errors, (2) wrong-site surgery (including the wrong side, wrong procedure, and wrong patient), and (3) delays in treatment. Contributing factors were most frequently associated with the human-computer interface, workflow and communication, and clinical content-related issues.


The classification of health IT-related contributing factors indicates that health IT-related events are primarily associated with the sociotechnical dimensions of human-computer interface, workflow and communication, and clinical content. Improved identification of health IT-related contributing factors in the context of the sociotechnical dimensions may help software developers, device manufacturers, and end users in health care organizations proactively identify vulnerabilities and hazards, ultimately reducing the risk of harm to patients.





Coleções: Bases de dados internacionais Base de dados: MEDLINE Assunto principal: Sistemas de Informação / Erros Médicos Aspecto clínico: Etiologia Limite: Humanos Idioma: Inglês Revista: Jt Comm J Qual Patient Saf Assunto da revista: Serviços de Saúde Ano de publicação: 2016 Tipo de documento: Artigo País de afiliação: Estados Unidos