IHI PS 103

Which of the following likely needs to be improved about the new process to review vital signs?

A process that has a lot of steps — some of which seem unnecessary — is a prime target for simplification. This is especially true for commonly used processes, such as reviewing and recording vital signs.

Which of the following concepts does this scenario demonstrate?

All of the above is the best answer. In this case, the computer has information, but not all of the information. The system does not seem to allow for the fact that there will sometimes be additional information that caregivers must take into account. Instead, it tries to force caregivers to follow rigid rules. Remember: Human beings must still be very present when interacting with technology to ensure its proper and effective use.

At the end of your training session on the new EHR, you are handed a two-sided laminated card titled "Quick Start Guide." It provides step-by-step instructions for basic tasks such as entering orders and writing daily notes in the EHR. This is an example of

Checklists, such as the laminated guide, alleviate your reliance on memory to help make sure you perform a given process (which is not automated and relies on you) correctly. There is nothing forcing you to use this checklist, and it isn't simplifying the steps in the process — just helping you remember them.

Which of the following types of errors is associated with controlled thinking?

Controlled thinking is when we consciously, often slowly, solve problems and make decisions. This is when errors of planning can occur, also known as "mistakes." In comparison, automatic thinking is rapid, effortless thought, during which we are vulnerable to what experts call skill-based errors, which include errors of execution or memory storage.

The first time you admit a patient to the hospital using the new EHR, you see a screen pop up as you are attempting to enter orders. At the top it says, "You must enter orders for DVT (blood clot) prevention before completion of this admission order set. Click here to complete this order." This pop-up box is an example of the use of

Forcing functions make it impossible to skip a task. Just as you cannot put a car into reverse unless your foot is on the brake, you cannot complete this particular admission order in this EHR unless you address the prevention of blood clots. This is not an example of simplification, as it actually adds a step. At the same time, it's not repeating a step, so it's not an example of redundancy.

Human factors is the study of

Human factors is an established science that uses many disciplines to understand how people perform under different circumstances. This engineering discipline deals with the interface of people, equipment, and the environment.

Which of the following statements about redundancies within processes is always true?

None of these statements is always true. In high-risk situations — such as the medication administration process — you may need redundancy to ensure safety. Although a typical redundancy involves one person checking the work of another, you can also use technology to "double check." It's important to keep in mind that it is possible for two people to make the same mistake and double checks can still allow the opportunity for error.

Effective ways for addressing defects in the human-technology interface include

Once designed, actual users should test technology in real-world situations. If users don't test the technology, then the possibility of introducing a faulty system goes up, which additional training would not address. Workarounds can lead to serious error; you should view them as a symptom of a poorly designed or overly complex system.

Which of the following is an example of unconscious processing by the brain?

Optical illusions and mistakes involving look-alike drugs and names reflect unconscious processing by the human brain. Unconscious processing is a fundamental part of human cognition that can lead to human error even when people are trying their best. Safe systems take these known characteristics of human cognition into account to help people do things the right way.

As a caregiver, which of the following common health IT issues would you be in the best position to help solve?

The best answer is incomplete data entries into the computer, which is a human-computer issue (as opposed to a computer issue). User feedback from caregivers is critical to improve the interfaces between computers and humans.

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you guess was the biggest contributor to this error?

The nurse was most likely fatigued after a double shift, which made her prone to error. We cannot sustain performance by merely trying hard and paying attention, and fatigue can affect performance no matter how hard you try or how excellent your training may be. When you are fatigued, you need processes that help prevent you from making an error, or mitigate the effects of an error if you do make one.

You're caring for a patient with diabetes who was admitted to your hospital with an elevated blood glucose level. She is on an insulin pump that is programmed to deliver one unit of insulin per hour through her intravenous (IV) line. How does this technology help make her care safer?

The pump automates the complex process of precisely administering insulin at regular intervals, helping make care safer for the patient. However, there's the chance the pump could malfunction, and providers dictate dosing decisions, so errors could still occur. Providers must always be present to ensure proper and effective use of technology.

Which of the following is a basic strategy for minimizing the opportunity for error in a process?

The science of human factors has helped us identify many design principles that can help prevent errors; standardizing processes is one such principle. Although we shouldn't be overly reliant on technology, technology can often be used to help prevent errors. Simply trying harder is not an effective error-prevention tactic.

When attempting to decrease the risk of error, it's important to use human factors principles because

Understanding how factors that affect human performance (such as fatigue, stress, and poor lighting) affect work and detract from one's ability to execute a safety-critical task (such as administering a medication, filling a prescription, or writing an order) can help you design processes and systems in ways that make them safer.

Which of the following is the best example of using technology to improve safety and prevent errors?

Using tablet technology to allow nursing assistants to record vital signs immediately (Answer B) is an example of using technology to make work safer. When vital signs are recorded much later than they're observed, the opportunities for error increase. Giving patients tablets (Answer A) may improve their inpatient experiences, but isn't as likely to prevent errors. Switching to a lower cost EHR platform may make good business sense (Answer C), but that decision won't directly affect patient safety. If providers are checking each other's work that can make care safer, but it's a social redundancy rather than a technology-based redundancy (Answer D).