The Joint Commission has received a sole source contract from the federal Office of the National Coordinator for Health Information Technology (ONC) to address a key recommendation made in the Institute of Medicine report “Health IT and Patient Safety: Building Safer Systems for Better Care.” The report called for an independent entity to help identify unsafe health information technology (health IT) conditions that have been associated with serious patient safety events, develop a process for preventing health IT-related adverse events, and educate the healthcare field and others about this work.
The primary objective of the contract is to establish a credible and meaningful process that can be used to identify, understand, disseminate and eventually help prevent health IT-related sentinel events that may cause serious or fatal harm. The results of the work will inform ONC’s “Health IT Patient Safety Action and Surveillance Plan” to use health IT to make care safer and continuously improve the safety of health IT.
As a component of its accreditation services, The Joint Commission’s Office of Quality Monitoring (OQM) regularly receives reports of sentinel events, including health IT-related sentinel events, from accredited organizations. The OQM staff routinely works with organizations to review their root cause analysis and aggregates data to increase public knowledge about sentinel events, their causes, and strategies for prevention. The Joint Commission will produce a final report describing investigations, identifying resources needed to effectively conduct investigations, describing risk management interventions and corrective actions, and identifying factors that may impact the ability of an external organization to conduct health IT-related investigations. Read the June 2013 ONC report to Congress on the adoption of health information technology.