1. The Culture of Healthcare Sociotechnical Aspects: Clinicians and Technology This material (Comp2_Unit10a) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. Lecture a

2. Sociotechnical Aspects: Clinicians and Technology Objectives – Lecture a Describe the concepts of medical error and patient safety (Lecture a, b) Discuss error as an individual and as a system problem (Lecture a) Compare and contrast the interaction and interdependence of social and technical “resistance to change” (Lecture c) Discuss the challenges inherent with adapting work processes to new technology (Lecture c) Discuss the downside of adapting technology to work practices and why this is not desirable (Lecture c) Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety (Lecture a, b) 2Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

3. Focus Of This Lecture Medical Errors and Patient Safety Medical errors: mistakes that occur during medical care Patient Safety: reduction in patient harm Reducing medical errors and improving patient safety are core aims of modern medicine 3Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

4. Medical Errors In 1964, one study published in the Annals of Internal Medicine reported that: –20% of patients admitted to a university hospital medical service suffered iatrogenic injury –20% of those injuries were serious or fatal In the U.S., medical errors are estimated to result in 44,000 to 98,000 unnecessary inpatient deaths annually 4Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

5. Adverse Events Adverse events occur in all healthcare systems and in all nations Data suggests a majority of these events occur in the hospital setting Other areas not immune to adverse events 5Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

6. Issues Facing Developing Nations In developing countries, other significant issues contribute to errors: –Infrastructure and equipment are inadequate –Drug supply and quality are unreliable –Some healthcare workers may have insufficient technical skills due to inadequacy of training –Operating costs are often underfinanced 6Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

7. Types Of Errors Errors Caused By Individuals: –Unintended acts of omission or commission –Acts that do not achieve their intended outcomes Errors Caused By Systems: –Complexity of healthcare and healthcare technology –Complexity of disease and dependence on intricate clinical collaborations and interventions 7Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

8. History Of Error Inquiry Prior focus of inquiry for errors was on the individual, and on the mistakes themselves –Investigations often reflected "name and blame" culture Now the focus is on the system – fixing inadequacies in the system can improve patient safety –Focus on system allows individuals to perform their tasks in a patient-care optimized environment 8Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

9. Individual Errors – Slips Some errors or “slips” are unconscious Usually a “glitch” when performing repetitive, routine actions Usually attention is diverted, and there is an unexpected break in the routine Attention can be impaired by many factors 9Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

10. Slips – Solving The Problem Need to limit opportunities for loss of attention Example: sleep deprivation during resident training Resident training in the US – limit to the number of duty hours per week to reduce slips due to fatigue and sleep deprivation 10Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

11. Individual Errors – Mistakes Some errors or “mistakes” are rule-based or knowledge-based – These are errors of conscious thought Rule-based errors -- usually occur during problem-solving when a wrong rule is applied Knowledge-based errors – usually occur when the decision-maker confronts a novel solution 11Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

12. Mistakes – Solving The Problem Rule-Based Errors –Use clinical decision support – order sets –Avoid bias in clinical reasoning Knowledge-Based Errors –Improve knowledge at the point of care –Foster culture of collaboration and consultation 12Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

13. System Errors System errors: these errors occur because of inadequacies within the system Often committed by multiple individuals who intersect with patient care Often difficult to analyze 13Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

14. Example: Medication Errors Unintended changes in medications occur in 33% of patients at the time of transfer from one unit to another within a hospital 14% of patients have unintended changes in their medications when they are discharged from the hospital More than half of patients have at least 1 unintended medication discrepancy at hospital admission 14Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

15. Medication Reconciliation Medication reconciliation: process of avoiding unintended changes in medication across transitions in care Requires iterative reviews of patient’s medications at different points of time during the hospital stay 15Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

16. Medication Reconciliation Methods for medication reconciliation: –Only pharmacists order medications –Linking process to computerized physician order entry (CPOE) –Integrating medication reconciliation in the EHR –Patients reconcile their medications instead of clinicians Studies suggest reduction in errors but have not yet demonstrated improvement in outcomes 16Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

17. Who is Driving Patient Safety Initiatives? Clinicians Hospitals Regulatory bodies – for example, the Joint Commission on Accreditation of Healthcare Organizations Patients 17Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

18. Sociotechnical Aspects: Clinicians and Technology Summary– Lecture a Focused on medical errors and patient safety Distinguished slips from mistakes The concept of system errors Examined the driving forces championing patient safety initiatives. 18Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a

19. Sociotechnical Aspects: Clinicians and Technology References – Lecture a References Auerbach, A., Landefeld, C., et al. (2007). The tension between needing to improve care and knowing how to do it. New England Journal of Medicine, 357: 608-613. Donabedian, A. (1988). The quality of care: how can it be assessed? Journal of the American Medical Association, 260: 1743-1748. Kohn, L., Corrigan, J., et al., eds. (2000). To Err Is Human: Building a Safer Health System. Washington, DC. National Academies Press. Krumholz, H. and Lee, T. (2008). Redefining quality -- implications of recent clinical trials. New England Journal of Medicine, 358: 2537-2539. Leape, L. (2000). Institute of Medicine medical error figures are not exaggerated. Journal of the American Medical Association, 284: 95-97. McGlynn, E., Asch, S., et al. (2003). The quality of Healthcare delivered to adults in the United States. New England Journal of Medicine, 348: 2635-2645. Nolte, E. and McKee, C. (2008). Measuring the health of nations: updating an earlier analysis. Health Affairs, 27: 58-71. Schimmel EM. The Hazards of Hospitalization. Ann Intern Med January 1, 1964 60:100-110 Sox, H. and Woloshin, S. (2000). How many deaths are due to medical error? Getting the number right. Effective Clinical Practice, 6: 277-283. The State of Healthcare Quality: 2009. Washington, DC, National Committee for Quality Assurance. http://www.ncqa.org/tabid/836/Default.aspx. http://www.ncqa.org/tabid/836/Default.aspx 19Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology Lecture a