1. Informatics Tools to Promote Patient Safety
Chapter 22
Informatics Tools to Promote Patient Safety

2. Objectives Explore the characteristics of a safety culture
Examine strategies for developing a safety culture
Recognize how human factors contribute to errors
Appreciate the impact of informatics technology on patient safety

3. Introduction
Nursing professionals have an ethical duty to ensure patient safety.
Increasing demands on professionals in complex and fast paced health care environments
May cut corners or develop workarounds that deviate from accepted and expected practice protocols.
These deviations are more often practiced in the interest of saving time or because the organizational culture is such that risky behaviors are commonplace.
Occasionally these inappropriate actions or omissions of appropriate actions result in harm or significant risk of harm to patients.

4. Safety Initiatives
1999 Institute of Medicine (IOM) report: To Err is Human
2001 IOM Quality Chasm report
Agency for Healthcare Research and Quality (AHRQ) launched initiatives focused on safety research for patients
2002 Joint Commission National Patient Safety Goals
2002 National Quality Forum (NQF) adverse events and ‘never events’ list,
Creation in 2004 of the Office of National Coordinator for Health IT to computerize health care,
2004 World health Organization’s (WHO) Alliance for patient safety,

5. Safety Initiatives, con’t
2005 Institute for Healthcare Improvement (IHI) 100,000 Lives campaign and Million Lives Campaign
2005 congressional authorization of Patient Safety Organizations (PSOs) created by the Patient Safety and Quality Improvement Act
to promote blameless error reporting and shared learning,
2008 “no pay for errors” Medicare initiative
$19 billion congressional appropriation to support electronic health records and patient safety

6. Key Features of a Safety Culture
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 (AHRQ, n.d., para. 1)

7. Failure Modes and Effect analysis
“Failure Modes and Effects Analysis (FMEA) is 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”(IHI, n.d.1 para. 1).
Access the tool here:

8. What is a Just Culture?
blame free environment to encourage error reporting
system or process issues that lead to unsafe behaviors and errors are addressed by changing practices or work-flows processes
clear message is communicated that reckless behaviors are not tolerated

9. Just Culture Error Types
Human Error (unintentional mistakes)
perform FMEA to understand error
Risky Behaviors (work arounds or cutting corners)
examine workflow; educate
Reckless Behavior (total disregard for established policies and procedures)
Enact zero tolerance policy; disciplinary measures

10. Promoting a Safety Culture
AHRQ suggests that teamwork training, executive walk-arounds, and unit based safety teams have improved safety culture perceptions, but have not demonstrated a significant reduction in error rates.
IHI strategies 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.

11. 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” (Ebben, Gieras, and Gosbee 2008, p 327).

12. Alarm Fatigue Medical equipment alarms frequently and inappropriately
May be related to the sensitivity of alarm parameters
Strategies to improve alarm response
improving the nurse call system by adding Voice Over Internet Protocol (VOIP) phones
feeding alarm data into a reporting database for further analysis
encouraging nurses to round with physicians to provide input into alarm parameters

13. Informatics Technologies and Safety
Improve communication
Reduce errors and adverse events
Increase the rapidity of response to adverse events
Make knowledge more accessible to clinicians
Assist with decisions
technology based forcing functions that direct or restrict actions or orders implemented by computer technologies.
Provide feedback on performance

14. Technologies to Support the medication Administration Cycle

15. Medication Administration cycle
Assessment of need
Ordering
Dispensing
Distribution
Administration
Evaluation
Human Error Factors: Distractions, unclear thinking, lack of knowledge, short staffing, and fatigue

16. Five Rights of Medication Administration
the right patient
the right time and frequency of administration
the right dose
the right route
the right drug

17. Technology Integration into Cycle
Reduces the potential for human errors by:
performing electronic checks
providing alerts to draw attention to potential errors
Tracks performance

18. Computerized Physician Order Entry (CPOE) Benefits
Prompts 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 sound alike;
Improved communication between physicians and pharmacists
Reduced healthcare costs due to improved efficiencies (The LeapFrog Group, 2008).

19. Technology in the Pharmacy
Verifying function is computer based, and the medication order is electronically checked via the knowledge database
Allergy verification and medication reconciliation with other drugs already in use
Barcode Medication labeling or RFID Technology
Assists with dispensing and administration
Automated dispensing machines
storage, dispensing, controlling, and tracking

20. Barcode Medication Administration (BCMA)
Provides a system of checks and balances to ensure medication safety
Nurse scans name badge thus logging in as the person responsible for medication administration.
patient’s barcode on the patient’s ID bracelet is scanned prompting the electronic system to pull up the medication orders.
the bar code on each of the medications to be administered is scanned.
This technology checks to ensure that the 5 rights of medication administration—right patient, right med, right dose, right route and right time—are met.

21. Smart Pump Technology
Designed for safe administration of high-hazard drugs and to reduce adverse drug events (ADE) during intravenous (IV) medication administration
Software is programmed to reflect the facility’s infusion parameters, and includes a drug library that compares normal dosing rates with those programmed into the pump.
Discrepancies generate an alarm alerting the clinician to a safety issue.

22. Clinical Decision Support (CDS)
Help a clinician select an appropriate medication
Will ensure that the order is complete (checks for drug interactions, duplications, or allergy contraindications, the right dose and right route
Provides double checks for interactions, allergies and appropriate dose orders during verification and dispensing.
Assists with infusion pump programming issues such as incompatibilities during infusion and proper notation and dispensing when portions of a dose must be wasted.

23. Clinical Decision Support (CDS), con’t.
Assists with patient identification and current assessment parameters (i.e. blood pressure, glucose level) that may contraindicate the use of the medication at that point in time.
Checks for interactions with foods or other medications
Provides patient education guidelines and printable handouts
The monitoring functions of the CDS provide a structured data reporting system to track side-effects and adverse events across the population

24. Technologies for Home Medication Compliance
eMedonline
collects patient medication compliance data by scanning package barcodes or RFID medication tags and using PDA or smart phone technology to send compliance data to the server
SIMpill® Medication Adherence System
uses web based technology to monitor patient compliance and provide reminders about taking medications or to refill prescriptions by sending text messages to the patient or caregivers

25. Home Medication Compliance, con’t
Caps of pill bottles may contain RFID tags that monitor and collect data on when the bottle is opened, or contain flashing time reminders when a dose is due (Blankenhorn, 2010).
Smart inhalers track asthma medication compliance using a microprocessor that records and stores medication compliance.

26. Other CDS Patient Safety Uses
data collection and data management functions help to ensure quality approaches to patient health challenges based on research evidence and clinical guidelines.
may also ensure cost-effectiveness by alerting clinicians to duplicate testing orders, or suggesting the most cost effective diagnostic test based on specific patient data

27. Expanded RFID Uses
patient tracking during procedures and testing, or function as part of the EHR communicating pertinent information to clinicians at the bedside
track medical supplies and equipment
imbedded into surgical supplies to automate supply counting procedures
reduce the likelihood of wrong patient, wrong site surgical procedures
reducing the potential that a counterfeit medication is inadvertently introduced into the supply, and providing for efficient medication recalls
specialized tags can detect temperature fluctuations and thus ensure that the blood or blood product was stored at the optimum temperature for safe administration

28. Smart Room Technology
RFID tag on employee name badge announces to the patient on a monitor exactly who has entered the room and triggers ‘need to know’ data by caregiver status to be displayed on the monitor in the room
Clinicians review patient data in real time and chart at the bedside using touch screen technology
alert clinicians as they enter the room about procedures that need to be implemented for the patient and can track individual clinician efficiency and effectiveness by aggregating data over time

29. Patient Monitoring Technologies
Body Area Networks or Patient Area Networks provide the ability to wear a small unobtrusive monitor that collects and transmits physiologic data via a cell phone to a server for clinician review
wireless chip on a disposable band-aid with a 5-7 day battery promises to be able to monitor the patient’s heart rate and electrocardiogram, blood glucose, blood pH, and blood pressure, allowing for the collection of important clinical data outside the hospital

30. Informatics Nurse Specialist Role
Ensure that the technology systems are properly configured and maintained.
Routinely monitor and check these systems while making sure that their human potential, the users, are capable of using the systems accurately to avoid errors.
Nurse informaticists must be involved in all stages of the system development life cycle (SDLC) with a focus on safety; safety concerns and remedies need to be analyzed, synthesized and integrated throughout the SDLC to have a robust tool that provides meaningful information and enhances patient care while preventing errors and promoting patient safety.

31. Thought Provoking Questions
What are the current patient safety characteristics of your organizational culture? Identify at least 3 aspects of your culture that need to be changed with regard to patient safety, and suggest strategies for change.
Describe a current technology that you use in patient care that would benefit from human factors engineering concepts. What are some ways this technology should be improved?
Identify a workaround that you have used and analyze why you chose this risk-taking behavior over behavior that conforms to a safety culture.