With the issues surrounding health information technology (IT) growing increasingly complex, The Joint Commission has released a new publication addressing the factors that impact technology’s safe use. The document follows up on Sentinel Event Alert 42, which was published in 2008 and discussed how to safely implement health IT and converging technologies and avoid adverse events.

In SEA 54, the organization examines how broader “socio-technical” factors such as workflow and communication issues, internal organizational policies, and human-computer interface challenges can increase risk and contribute to health IT errors. The document recommends specific actions targeted to three key areas: safety culture, process improvement, and leadership. Suggestions include limiting the number of patient records that can be displayed on a screen at one time to avoid entry errors, conducting downtime drills, and establishing redundant hardware systems.

The full document can be downloaded free of charge on The Joint Commission website.