Working with Health IT Systems Lecture a This material (Comp7_Unit6a) was developed by Johns Hopkins University, funded by the Department of Health and.

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Unit 6: HIT Facilitated Error – Cause and Effect

Unit 6a: HIT Facilitated Error – Cause and Effect

Component 1: Introduction to Health Care and Public Health in the U.S.

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Working with Health IT Systems Lecture a This material (Comp7_Unit6a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC HIT Facilitated Error— Cause and Effect

HIT Facilitated Error—Cause and Effect Learning Objectives Lecture a Explain the concept of facilitated error in HIT Cite examples of situations where HIT systems could increase the potential for user error Analyze sources of HIT facilitated errors and suggest realistic solutions 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a

Error in Healthcare 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a

The Quaid Twins—Movie 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a

Error in Healthcare High Stress – Distraction - Busy Cognitive Limitations Stuck in Thinking Unclear Directions Unclear Labeling/Poor Layout –Juxtaposition ‘‘ I was ordering Cortisporin, and Cortisporin solution and suspension comes up. The patient was talking to me, I accidentally put down solution, realized that’s not what I wanted.... I would not have made that mistake, or potential mistake, if I had been writing it out because I would have put down what I wanted.’’ ( Ash, Berg, Coiera, 2004 ) 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a

Error in Healthcare 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a Role Change/Communication Change/Workflow Change Undue Trust? Currency & Appropriateness Alert Fatigue System Rigidity

HIT Facilitated Error— Cause and Effect Summary—Lecture a Error causation in healthcare –High Stress – Distraction; Cognitive Limitations; Stuck in Thinking; Unclear Directions; Unclear Labeling/Poor Layout –Role Change/Communication Change/Workflow Change; Undue Trust; Currency & Appropriateness; Alert Fatigue & System Rigidity 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a

HIT Facilitated Error—Cause and Effect References—Lecture a References Ash J., Berg, M., Coiera, E. Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors Available from: Images Slide 1: Navy Officer Examining a Paper Medical Record. Image Courtesy US Dept. of Navy. Available from: 061_U.S._Navy_Hospital_Corpsman_Joseph_Malandro_from_Haddon_Township,_N.J.,_files_medical_records_at _the_Michaud_Medical-Dental_Facility.jpg 061_U.S._Navy_Hospital_Corpsman_Joseph_Malandro_from_Haddon_Township,_N.J.,_files_medical_records_at _the_Michaud_Medical-Dental_Facility.jpg Slide 2: Operating Room Team. Available from: Attribution-ShareAlike 2.0 Generic (CC BY-SA 2.0) Marion Doss Slide 3: Nurse Checking a Man's Blood Pressure. Courtesy Dr. Patricia Abbott Slide 4: Heparin Bottles with the URL to the Quaid Twins Movie. Available from: deaths-reported-as-baxter-expands-heparin-recall.aspx?googleid=29868http://news.injuryboard.com/more- deaths-reported-as-baxter-expands-heparin-recall.aspx?googleid=29868 Attribution-NonCommercial-ShareAlike 3.0 Unported (CC BY-NC-SA 3.0) Injury Board National Newsdesk Slide 5: Heparin Bottles. Available from: heparin-recall.aspx?googleid=29868http://news.injuryboard.com/more-deaths-reported-as-baxter-expands- heparin-recall.aspx?googleid=29868 Attribution-NonCommercial-ShareAlike 3.0 Unported (CC BY-NC-SA 3.0) Injury Board National Newsdesk Slide 6: Woman Looking at Man Suspiciously. Available from: Attribution-NonCommercial-ShareAlike 2.0 Generic (CC BY-NC-SA 2.0) Trevin Chow 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Working with Health IT Systems HIT Facilitated Error—Cause and Effect Lecture a