Which sentinel events related to health IT are most common in ambulatory settings? According to a research collaboration between The Joint Commission and the the Office of the National Coordinator, sentinel events in ambulatory settings have the potential to seriously impact patient care. The research partnership uncovered the following:
1. Between 2010 and 2013, there were 120 de-identified sentinel events with more than 300 health IT contributing factors reported to The Joint Commission.
2. The most frequent consequences of the health IT sentinel events were medication errors, wrong-site surgeries/procedures and delays in treatment.
3. The top three health IT factors contributing to the sentinel events were human-computer interface issues, technology impeding clinical workflow and clinician communications.
The Joint Commission’s Ambulatory Buzz blog offers more information and resources on health IT safety in ambulatory settings.
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