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PSNet: Patient Safety Network
Sentinel Event Alerts

Safely implementing health information and converging technologies.

Sentinel event alert. 2008:1-4.

As health information technologies such as computerized provider order entry are implemented more widely, awareness of the unintended consequences of these technologies has increased. Both electronic medical records and computerized order entry have been associated with significant problems relating to altered workflow and communication patterns. This sentinel event alert from the Joint Commission reviews the types of adverse events associated with information technology and gives detailed recommendations for how institutions should integrate new technologies. The alert stresses the importance of involving frontline staff in the development and implementation process and also recommends careful postimplementation monitoring for errors and near misses associated with new technology.