Informatics Tools to Promote Patient Safety, Quality Outcomes, and Interdisciplinary Collaboration (Week 6)

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, 2012, para. 1). -Access the tool at: Institute for Healthcare Improvement: Failure Mode and Effects Analysis (FMEA) Tool (ihi.org)

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, & Gosbee, 2008, p 327).

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) World Alliance for Patient Safety

Safety Initiatives (cont.)

-2005 Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign and 2008 5 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 (EHRs) and patient safety

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.

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, 2012, para. 1)

Medication Administration Cycle

-Assessing need -Ordering -Dispensing -Distributing -Administering -Evaluating -Human error factors: Distractions, unclear thinking, lack of knowledge, short staffing, and fatigue

Clinical Decision Support (CDS) (cont.)

-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 -Monitoring functions provide a structured data reporting system to track side effects and adverse events across the population

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 workflows/processes. -Clear message is communicated that reckless behaviors are not tolerated.

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 cellphone 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

Technologies for Home Medication Compliance (cont.)

-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.

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.

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; 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.

Health Informaticist's 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. -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.

Introduction

-Healthcare professionals have an ethical duty to ensure patient safety. -Increasing demands on professionals in complex and fast-paced healthcare 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.

Clinical Decision Support (CDS)

-Helps a clinician select an appropriate medication -Ensures that the order is complete (checks for drug interactions, duplications, or allergy contraindications, 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

Just Culture Error Types

-Human error (unintentional mistakes) -Perform FMEA to understand error -Risky behaviors (workarounds or cutting corners) -Examine workflow; educate -Reckless behavior (total disregard for established policies and procedures) -Enact zero tolerance policy; disciplinary measures

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.

Alarm Fatigue

-Medical equipment alarms frequently and inappropriately -May be related to the sensitivity of alarm parameters -Strategies to improve alarm response -Improve the patient call system by adding voice over Internet protocol (VOIP) phones -Feed alarm data into a reporting database for further analysis -Encourage healthcare professionals to round with physicians to provide input into alarm parameters

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 -Reduce the potential that a counterfeit medication is inadvertently introduced into the supply, and provide 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

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 (LeapFrog Group, 2008)

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. -Barcode on the patient's ID bracelet is scanned prompting the electronic system to pull up the medication orders. -Barcode on each of the medications to be administered is scanned. -This technology checks to ensure that the five rights of medication administration—right patient, right med, right dose, right route, and right time—are met.

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.

Technology Integration into Cycle

-Reduces the potential for human errors by -Performing electronic checks -Providing alerts to draw attention to potential errors -Tracks performance

Most Frequent Safety Issues

-The National Patient Safety Foundation (NPSF) top patient safety issues (2013): -Wrong site surgery -Hospital acquired infections -Falls -Hospital readmissions -Diagnostic error -Medication errors -Many of these issues can be prevented or early detected using informatics technologies.

Technology in the Pharmacy

-Verifying function is computer based; 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

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

Five Rights of Medication Administration

1.The right patient 2.The right time and frequency of administration 3.The right dose 4.The right route 5.The right drug