The Joint Commission has confirmed what many physicians have long suspected: For all the hope that gee-whiz technology can improve quality and safety, even the smartest machines can lead to medical errors.
The commission, which accredits hospitals and other health care organizations, warned in a December 2008 sentinel event alert that “not only must the technology or device be designed to be safe, it must also be operated safely within a safe work flow process.”
At least 10% of harmful medication mistakes are technology-related failures, according to U.S. Pharmacopeia’s Medmarx voluntary drug error-reporting database. Everything from barcodes that fail to scan to confusing computer screen displays were to blame, USP’s 2008 report said.
Other studies have found that computerized physician order entry systems facilitate 22 different types of medical mistakes, while nurses frequently skip scanning barcodes to work around poorly implemented systems.
“Computers don’t make us less stupid,” said Joint Commission President Mark Chassin, MD, MPH, in a news conference. “They make us stupid faster.”
The whole shebang.