A Sentinel Event Alert released by The Joint Commission last spring focuses on the safe use of health information technology (health IT). The alert builds on Sentinel Event Alert #42, released in 2008, which provided guidance for safely implementing health information and converging technologies.
In developing Sentinel Event Alert #54, The Joint Commission analyzed 3,375 sentinel events that resulted in permanent patient harm or death from January 1, 2010, to June 30, 2013. Within that sampling, 120 events were identified as having health IT-related contributing factors. Researchers then categorized the factors contributing to the 120 events into eight corresponding socio-technical dimensions described in the alert.
To learn more about the factors that can lead to Health IT sentinel events and TJC’s suggested actions for mitigating risk, click here.
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