IHI: PS 103: human factors and safety

Which of the following statements about computerized prescriber order entry systems (CPOEs) is true? (A) Several studies have disputed the claim that they reduce errors. (B) They eliminate the possibility for error by eliminating the reliance on human memory. (C) They typically interfere with workflow while providing few benefits. (D) A and C

(A) Several studies have disputed the claim that they reduce errors.

What are some issues that impact human performance and increase risk for error

1. factors before action takes place (predisposing mental and physiological states) 2. factors that directly enable decision making: perception, attention, memory, reasoning 3. factos that directly enable decision execution: communication

What categories are cognitive dispositions to respond in the medical field?

1. faulty assessment of probability overestimating the likelihood of something 2. failure to seriously consider all relevant possibilities

What is Cognitive dispositions to respond?

predictable ways that humans misjudge situations

what is an example of a constraint?

removal of concentrated electrolytes (lethal) and placed in another location and restricted until appropriate checks are used

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient's vital signs, you could simply look at the sheet of paper clipped onto the end of the bed. Which of the following likely needs to be improved about the new process to review vital signs? (A) It needs to be simplified. (B) It needs to be standardized. (C) It needs redundancies added. (D) It needs to avoid reliance on memory.

(A) It needs to be simplified.

Which of the following is the best example of using technology to improve safety and prevent errors? (A) Providing inpatients with electronic tablets so that they can keep in better touch with the outside world (B) Giving nursing assistants electronic tablets to ensure there's no delay in recording patients' vital signs (C) Switching to an electronic health record (EHR) platform that is of comparable quality but lower cost (D) Implementing redundancies, in which providers double-check each other's electronic inputs

(B) Giving nursing assistants electronic tablets to ensure there's no delay in recording patients' vital signs

how do electronic medical records help improve the quality of care?

by understanding the patient population's health as a whole

Computerized prescriber order entry systems (CPOEs)

can provide alerts for drug interactions and therapeutic duplication

What is an example of forcing function?

car won't use cruise if ground is wet

what do bar coding systems help with?

effective medication administration and inventory control

if a process is too complex what do users find?

a simpler way (usually more dangerous) called workaround

what are External/exogenous causes of error?

factos related to the situation the individual is in -noise, heat, light -long work hours -inadequate training -poorly designed rules or procedures -interruptions and distractions -language barriers

what is the most common physiologic factor that can lead to error in both automatic and controlled thinking?

fatigue

bar coding systems

they help identify medical personnel for security reasons using personal identification badges. Medication bar-coding systems can help identify medications and match them to the correct patient.

Redundancies are needed in which of the following circumstances? (A) When a secondary system is needed in the event a first system fails (B) Within any process in health care (C) Within a situation where a failure in the first step can result in serious harm (D) Within processes in which redundancies will not take more time

Answer: A and C. Although not every process in health care requires a redundancy, it is important to have one when a primary system can fail and such failure would result in harm.

Why is the double check not as effective?

The second person may not be as attentive to the checking as he or she should be. The second person can be influenced by the first person to see what he or she would expect. Double checks can be overused, making people less likely to take them seriously.

what are forcing functions?

make it impossible to do a task incorrectly. They create a hard stop that you cannot pass unless you change your actions.

what type of thinking leads to errors of planing

controlled thinking

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient's vital signs, you could simply look at the sheet of paper clipped onto the end of the bed. 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: (A) A forcing function (B) Simplification (C) Redundancy (D) A and B

(A) A forcing function

when working as a team what do members gain?

better understanding of the other members' competence and reliability

Which of the following is a basic strategy for minimizing the opportunity for error in a process? (A) Reducing reliance on technology (B) Standardizing how the process is completed (C) Trying harder to perform the process correctly (D) A and C

(B) Standardizing how the process is completed

what is a typical redundancy?

a double check one person checks the work of another person

What do heuristics lead to?

incorrect actions and poor decision making

Effective ways for addressing defects in the human-technology interface include: (A) Providing in-person user training on using the technology (B) Testing the technology in real-world situations (C) Encouraging users to find workarounds (D) All of the above

(B) Testing the technology in real-world situations

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. Which of the following is a risk of this technology? (A) The pump is dictating rather than facilitating your work. (B) The pump could malfunction. (C) There is no risk associated with the pump. (D) A and B

(B) The pump could malfunction.

You're working in an outpatient clinic that recently started using an electronic health record (EHR). You are entering a prescription for an antibiotic into the EHR to treat Mrs. Jones's urinary tract infection. As you enter the order, a warning screen pops up saying that she has chronic kidney disease, and the medication dose should be adjusted based upon her last recorded creatinine level (a measure of kidney function). However, you know that Mrs. Jones's most recent creatinine level — recorded at a different clinic and therefore not available in your EHR — came back normal. When you attempt to move past the warning, the system will not allow you to proceed. What does this block best exemplify? (A) How technology can be used to make patient care safer (B) How technology can be used to make care more efficient (C) How technology that dictates your work — rather than facilitates it — can introduce unintended problems (D) A and B

(C) How technology that dictates your work — rather than facilitates it — can introduce unintended

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? (A) The pump eliminates the need for providers to be involved in her care. (B) The pump eliminates the possibility of a medication error. (C) The pump helps automate a complex care process. (D) All of the above

(C) The pump helps automate a complex care process.

Which of the following statements about bar-cording systems is true? (A) They typically offer few benefits and merely promote workarounds. (B) They can completely prevent medication errors. (C) They can help providers keeps track of laboratory specimens, identify medications and medical equipment, and identify patients. (D) B and C

(C) They can help providers keeps track of laboratory specimens, identify medications and medical equipment, and identify patients.

Effective ways for addressing defects in the human-technology interface include: (A) Involving the user in the design of the technology (B) Testing the technology under real-life conditions (C) Reducing the cost of the technology (D) A and B

(D) A and B

You're working in an outpatient clinic that recently started using an electronic health record (EHR). You are entering a prescription for an antibiotic into the EHR to treat Mrs. Jones's urinary tract infection. As you enter the order, a warning screen pops up saying that she has chronic kidney disease, and the medication dose should be adjusted based upon her last recorded creatinine level (a measure of kidney function). However, you know that Mrs. Jones's most recent creatinine level — recorded at a different clinic and therefore not available in your EHR — came back normal. When you attempt to move past the warning, the system will not allow you to proceed. Which of the following concepts does this scenario demonstrate? (A) Technology can introduce unintended problems. (B) Technology should facilitate how you do your work, not dictate it. (C) Human beings must still be very present when interacting with technology to ensure its proper and effective use. (D) All of the above

(D) All of the above

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient's vital signs, you could simply look at the sheet of paper clipped onto the end of the bed. 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: (A) Using forcing functions and constraints (B) Automating carefully (C) Simplifying (D) Avoiding reliance on memory

(D) Avoiding reliance on memory

Which of the following is the best example of using technology to improve safety and prevent errors? (A) Switching to an electronic health record (EHR) platform that is of comparable quality but lower cost (B) Implementing redundancies, in which providers double-check each other's electronic inputs (C) Providing inpatients with electronic tablets so that they can keep in better touch with the outside world (D) Giving nursing assistants electronic tablets to ensure there's no delay in recording patients' vital signs

(D) Giving nursing assistants electronic tablets to ensure there's no delay in recording patients' vital signs

Which of the following statements about redundancies within processes is always true? (A) They are needlessly inefficient. (B) They remove the opportunity for error. (C) They require two people to do the work of one. (D) None of the above

(D) None of the above

what is one of the best ways to reduce errors related to performance?

standardize this eliminates the variation and confusion and promotes predictability and consistency

How do you take advantage of habits and patterns?

taking your meds after you brush your teeth will increase compliance

How is our mental function defined as

automatic thinking rapid and effortless

What is controlled thinking

consciously solve problems and make decisions sometimes this can be a slow process involving a great deal of effort.

Electronic medical and health records

digital patient files track health information over time, easily identify patients who are eligible for preventive visits and screenings, monitor key health indicators such as blood pressure

What are endogenous/ internal causes?

factors related to the individual physiological states that cloud our judgement and though processes -limited memory capacity -fatigue -stress -language limitations -hazardous attitudes

what doe pharmacy computer systems do?

help track medication doses and inventory, number of clinical interaction features - including drug interaction testing -therapeutic duplication checks -dose checks - impact of laboratory values on dosing.

What are mental short cuts your brain uses during controlled and automatic thinking called?

heuristics

intravenous medication infusion pumps control what

how quickly a medication is administered.

what is an error of execution?

if your gas tank is on the right but your friends is on the left if you pull up to the pump with the tank on the right

Computerized prescriber order entry systems reduce the ...

reliance on the human memory eliminate confusion from poor handwriting and and connect with lab systems to check that lab values that impact drug doses

what do IV med infusion pumps compare

the dose of a medication programmed by a nurse into the computer with a predetermined appropriate value. If the programmed dose exceeds the limit of the predetermined value, the computer will alert the user.

what are constraints?

the state of being checked, restricted, or compelled to avoid or perform some action OTC cough meds need to be unlocked by a clerk

what does standardization result in?

uniform and common way of completing a task reduces the complexity and variation

what is the goal of the checklist?

use it as a guide to completing the tasks on the checklist