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CHAPTER 12: Informatics Tools to Promote Patient Safety, Quality Outcomes, and Interdisciplinary Collaboration
Introduction:
Sentinel event - A patient safety issue that results in death, permanent harm, or serious temporary harm requiring intervention
What Is a Culture of Safety:
To Err Is Human is widely credited for launching the current focus on patient safety in health care.
Key features of a safety culture identified by the AHRQ are as follows:
Acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations.
A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment.
Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems.
Organizational commitment of resources to address safety concerns.
An important part of the safety culture is cultivating a blame-free environment. Errors and near misses must always be reported so that they can be thoroughly analyzed to ascertain changes needed to prevent reoccurrence. All organizations can learn from mistakes and change their organizational processes or culture to ensure patient safety.
The Patient Safety and Quality Improvement Act of 2005 - Mandated the creation of a national database of medical errors and funded several organizations to analyze these data with the goal of developing shared learning to prevent healthcare errors.
Organizations themselves can engage in root-cause analysis or failure modes and effects analysis (FMEA) to examine healthcare system errors closely and to determine the system processes that need to be changed to prevent similar future errors.
A tool for implementing root-cause analysis has three goals; it was designed to determine “what happened, why did it happen, and how to prevent it from happening again”.
Failure Modes and Effects Analysis (FMEA) - A systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.
Just culture - An atmosphere of trust. In a just culture, everyone understands what is acceptable and unacceptable behavior, and they are rewarded for ensuring safety.
One way to balance competing cultural values (blameless versus accountability) is to establish a “just culture” in which system or process issues that lead to unsafe behaviors and errors are addressed by changing practices or workflow processes and a clear message is communicated that reckless behaviors are not tolerated.
The “just culture” approach accounts for three types of behaviors leading to patient safety compromises:
Human error (unintentional mistakes).
Risky behaviors (work-arounds).
Reckless behavior (total disregard for established policies and procedures).
Strategies for Developing a Safety Culture:
The AHRQ suggested that teamwork training, executive walk-arounds, and unit-based safety teams have improved safety-culture perceptions but have not led to a significant reduction in error rates.
AHRQ recommended seven steps of action planning:
Understand survey results.
Communicate and discuss survey results.
Develop focused action plans.
Communicate action plans and deliverables.
Implement action plans.
Track progress and evaluate impact.
Share what works.
Informatics can assist with the analysis, trending, synthesis, and dissemination of the action plan results.
Organizational leaders must drive culture change by making a visible commitment to safety and enabling staff to share safety information openly.
Some strategies suggested by the IHI include appointing a safety champion for every unit, creating an adverse event response team, and reenacting or simulating adverse events to better understand the organizational or procedural processes that failed.
Leadership oversight and support is critical to ongoing sharing and, most importantly, collaborative solution development to provide safe care and achieve quality outcomes for all patients.
Human factors engineering - The discipline of applying what is known about human capabilities and limitations to the design of products, processes, systems, and work environments.
Its application to system design improves “ease of use, system performance and reliability, and user satisfaction, while reducing operational errors, operator stress, training requirements, user fatigue, and product liability”.
Testing human use factors provides more objective safety data than the subjective responses gained from user preference testing.
Information chaos is defined as:
Information overload (i.e., too much unnecessary information).
Information underload (i.e., missing or not enough information).
Information scatter (i.e., information located in many different places and difficult to find).
Erroneous or conflicting information.
The typical patient safety beliefs that harms are inevitable, data silos are natural and heroism is the norm “have inadvertently provided excuses for not addressing patient safety comprehensively.”.
ALARA (As Low As Reasonably Achievable) - Safety principle designed to minimize radiation doses and releases of radioactive materials.
Patient safety issues identified in medical imaging can be mitigated by informatics tools. Medical imaging safety issues are categorized into active failures and latent failures:
Latent failures - Related to technical, system-related, and reporting defects (including defective documentation, incorrect or incomplete information, and communication loop failure).
Active failures - Are human failures, patient-based failures, and external failures.
Medical sonographers’ computer skills are not keeping pace with the technological advances.
Once a technology is integrated into the organization, biomedical engineers can become valuable partners in promoting patient safety through appropriate use of these technologies.
Teaching patient safety (PS) and quality improvement to health professions students is a relatively new concept but has been recognized as vital to the future of health care.
Three key gaps where better information could help guide hospital officials in their continued efforts to implement patient safety practices.
These gaps involve a lack of:
Information about the effect of contextual factors on implementation of patient safety practices.
Sufficiently detailed information on the experience of hospitals that have previously used specific patient safety implementation strategies.
Valid and accurate measurement of how frequently certain adverse events occur.
Informatics Technologies for Patient Safety:
Healthcare technologies are frequently designed to improve patient safety, streamline work processes, and improve the quality and outcomes of healthcare delivery.
The overall safety and effectiveness of technology in health care ultimately depends on its human users, and any form of technology can have a negative impact on the quality and safety of care if it is designed or implemented improperly or is misinterpreted.
Although technology may certainly help to prevent or reduce errors, one must always remember that technology is not a substitution for safety vigilance by the healthcare team in a safety culture.
Patient safety should always be at the center of the design and adoption of any technology introduced into patient care settings. Technology that’s designed to improve patient safety is only as good as the person using the device. It doesn’t replace critical thinking, solid nursing practice, and careful patient monitoring.
Medication errors are the most frequent and the most visible errors because the medication administration cycle has many poorly designed work processes with several opportunities for human error.
Computerized physician order entry (CPOE), automated dispensing machines, smart pump technologies for intravenous drug administration, and bar-code medication administration (BCMA) frequently preceded the adoption of the EHR in many institutions because of the costs associated with implementing these technologies.
In the early EHR systems, clinicians were prompted by electronic alerts reminding them of important interventions that should be part of the standard of care, but these alerts tended to be generalized and not patient specific.
The National Patient Safety Foundation (2013) listed the top patient safety issues as:
Wrong-site surgery.
Hospital-acquired infections.
Falls.
Hospital readmissions.
Diagnostic errors.
Medication errors.
Many of these issues can be prevented or detected in their early stages using informatics technologies
Technologies to Support the Medication Administration Cycle:
The steps in the medication administration cycle:
Assessment of need.
Ordering.
Dispensing.
Distribution.
Administration.
Evaluation.
Each step depends on vigilant humans to ensure patient safety, resulting in the five rights of medication administration:
The right patient.
The right time and frequency of administration.
The right dose.
The right route.
The right drug.
Human error can affect many aspects of this cycle.
Distractions, unclear thinking, lack of knowledge, short staffing, and fatigue are a few of the factors that cause humans to deviate from accepted safety practices and commit medication errors.
CPOE is an electronic prescribing system designed to support physicians and nurse practitioners in writing complete and appropriate medication and care orders for patients.
Specific benefits of CPOE include the following:
Prompts that warn against the possibility of drug interaction, allergy, or overdose.
Accurate, current information that helps physicians keep up with new drugs as they are introduced into the market.
Drug-specific information that eliminates confusion among drug names that look and sound alike.
Reduced healthcare costs caused by improved efficiencies.
Improved communication between departments such as doctors, nurses, specialists, pharmacists, clinicians. and patients.
Improved clinical decision support at the point of care.
CPOE solves the safety issues associated with poor handwriting and unclear or incomplete medication orders.
Bar code - A series of alternating bars and spaces that represent a unique code that can be read by a special bar-code reader. Bar-code technology spans both the medication dispensing and the administration steps in the medication administration cycle.
In the pharmacy, the bar code helps to ensure that the right drug and the right dose are dispensed by the pharmacy.
In a free-standing eMAR without CDS or EHR links, if the medication orders have recently been changed, the nurse is alerted to the change. When an alert is generated, the nurse must chart the action taken in response to that alert.
Medications that are labeled individually by the in-house pharmacist increase the potential for human error if the medication is given an incorrect bar code, such as one signifying a wrong dose or even a wrong medication.
Recommendations to reduce BCMA errors:
Purchase unit-of-use medications with manufacturer bar codes whenever possible.
Double-check all hospital-generated bar-code labels, including those for compounded injectable medications, before the product leaves the pharmacy.
Carefully review all BCMA override reports. Address system work-arounds through process change and staff education.
Minimize false-positive warnings to reduce the likelihood that staff will ignore warnings for real errors.
Ensure that an urgent need exists for all “stat” orders because pharmacy review and advantages of bar-code administration are usually circumvented in such cases.
Establish institutional policies and procedures that can be easily implemented when products fail to scan. Processes in pharmacy will likely be different than processes at the point of care.