Nursing Informatics Ch.15: Informatics Tools to Promote Patient Safety, Quality Outcomes, and Interdisciplinary Collaboration

RFID's can reduce

never events of wrong-patient, wrong-site surgical procedures

Government Accountability Office (GAO)

number one challenge they identifide was obtaining data to identify adverse reactions in their own hospitals

Alarm, alert, and notification overload

numerous alarms may cause a clinically significant issue to be missed

Information underload

missing or not enough information

Just Culture Approach accounts for three types of behaviors:

(1) human error (i.e., unintentional mistakes) (2) risky behaviors (i.e., workarounds) (3) reckless behavior (i.e., total disregard for established policies and procedures)

Blame free culture

-An important part of of safety culture -Errors and near misses must always be reported so they can be thoroughly analyzed to ascertain changes needed to prevent reoccurrence

information chaos is:

-Information overload -Information underload -Information scatter -Erroneous or conflicting information

BCMA

-Nurse begins by scanning his or her name badge, thereby logging in as the person responsible for medication administration. -Next, the bar code on the patient's identification bracelet is scanned, which prompts the electronic system to pull up the medication orders. -Next, the bar code on each of the medications to be administered is scanned.

following steps to ensure safe implementation of smart pump technology:

-Prior to deploying these pumps, standardize dosing units for a given drug (for example, agreeing to always dose nitroglycerin in terms of mcg/min or mcg/kg/min but not both). Asking a nurse to choose among several dosing units increases the risk of selection error. -Prior to deploying these pumps, standardize drug nomenclature -Perform a Failure Modes and Effects Analysis (FMEA)

Specific benefits of a CPOE system include the following:

-Prompts that 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 look and sound alike -Reduced healthcare costs caused by improved efficiencies -Improved communication among doctors, nurses, specialists, pharmacists, other clinicians, and patients -Improved clinical decision support at the point of care

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)

The medical technology hazards identified by the ECRI were as follows:

1.Surgical staplers 2.Point-of-care 3.Infection risks from sterile processing 4.Hemodialysis risks with central venous catheters 5.Surgical robotic procedures 6.Alarm, alert, and notification overload 7.Cybersecurity risks in the home health setting 8.Missing implant data for MRI scan patients 9.Medication errors from dose timing discrepancies in electronic medical records 10.Loose nuts and bolts in medical devices (Many of these issues can be prevented or detected in their early stages using informatics technologies, although we do see continued struggles with the same safety issues over several years)

sentinel event

A patient safety issue that results in death, permanent harm, or serious temporary harm that requires intervention

Smart rooms

As a caregiver enters the room, the RFID tag on his or her name badge announces to the patient on a monitor (typically mounted on the wall in the patient's line of sight) exactly who has entered the room and triggers "need to know" data based on caregiver status to be displayed on the monitor in the room, thus complying with the Health Insurance Portability and Accountability Act (HIPAA)

right channels

EHR, mobile device, patient portal

1. The right information (what) 2. To the right person (who) 3. In the right format (how) 4. Through the right channel (where) 5. At the right time (when)

Five Rights of CDS

Apps:

If data are being exchanged, patients must comprehend what data will be collected and where, when, and with whom they will be shared.

Joint Commission's

National Patient Safety Goals (updated yearly since 2002)

-venous -thromboembolism -mental health -pediatric adverse drug events

Patient Safety Movement Initiative's 3 new patient safety challenges

Just culture:

People are encouraged, even rewarded, for providing essential safety-related information, but clear lines are drawn between human error and at-risk or reckless behaviors

Learning culture:

People are willing and competent to draw the right conclusions from safety information systems and willing to implement major reforms when their need is indicated.

Reporting culture:

People report their errors and near misses.

Goal 6 of the 2020 Hospital National Patient Safety Goals of the Joint Commission

Reduce patient harm associated with clinical alarm systems

-Just Culture -Reporting Culture -Learning Culture

Three Characteristics of a Safety Culture

GAO 3 key gaps

a lack of: (1) information about the effect of contextual factors on implementation of patient safety practices, (2) sufficiently detailed information on the experience of hospitals that have previously used specific patient safety implementation strategies, (3) valid and accurate measurement of how frequently certain adverse events occur

National Quality Forum's

adverse events and "never events" list (2002)

smart room workflow algorithms

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

iScrub

an app that is used to monitor hand hygiene, which could help prevent healthcare-associated infections

CPOE (Computerized Provider Order Entry)

an electronic prescribing system designed to support physicians and nurse practitioners in writing complete and appropriate medication and care orders for patients

Systems Engineering

approach to patient safety which technology manufacturers partner with organizations to identify risks to patient safety and promote safe technology integration

Applications (apps)

are being used by and prescribed for patients. The apps used for patient education can engage and inform patients; an educated patient is believed to be "more likely to understand risks and if there is an adverse event, may be less likely file a lawsuit"

Steps of Medication Administration Cycle

assessment of need ordering dispensing distribution administration evaluation

bar code (medication)

bar code helps to ensure that the right drug and the right dose are dispensed by the pharmacy. Medications that are labeled with bar codes can also be dispensed by robots capable of reading the codes or automated dispensing machines.

biomedical engineers

become valuable partners in promoting patient safety through appropriate use of these technologies helped to revamp processes associated with the new technology alarm systems after they discovered several key issues: slow response times to legitimate alarms and multiple false alarms (promoting alarm fatigue)

root-cause analysis or failure modes and effects analysis (FMEA)

both of which are systems analyses to examine medical errors closely to determine the system processes that need to be changed to prevent similar future errors

Informatics

can assist with the analysis, trending, synthesis, and dissemination of the action plan results.

CPOE orders

can be entered in seconds and from remote sites, thereby eliminating the use of verbal orders, which are especially subject to interpretation errors. Orders are then transmitted electronically to the pharmacy, thus reducing the potential for transcription errors that are commonly encountered in the former paper-based system, such as lost or misplaced orders, delayed dosing, or unreadable faxes

smart pump: soft alarm

can typically be overridden by a clinician at the bedside

ADCs (automated dispensing cabinets)

carries out processes of drug storage, dispensing, controlling, and tracking are easily benefits for both the user and the organization, specifically in the areas of access security (especially with narcotics administration tracking), safety, supply chain, and charge functions

early EHR systems

clinicians were prompted by electronic alerts to remind them of important interventions that should be part of the standard of care, but these alerts tended to be generalized and not patient specific Examples: Did you check the allergy profile?" or "Has the patient received a pneumonia immunization?

RFID system

contains a tag affixed to an object or a person that functions as a radio-frequency transponder and provides a unique identification code, a reader that receives and decodes the information contained on the tag, and an antenna that transmits the information between the tag and the reader.

interprofessional collaboration

crucial when caring for patients because the open exchange of ideas, experience, and knowledge helps the professionals develop a comprehensive plan of care

Smart pump technologies

designed for safe administration of high-hazard drugs and reducing adverse drug events during IV medication administration, have software that is programmed to reflect the facility's infusion parameters and a drug library that compares normal dosing rates with those programmed into the pump.

Internet of Things (IoT)

device located at the bedside that allows the patient to use voice commands to control the room (i.e., temperature and lighting), search for health-related information, and improve communication with clinicians

Loose nuts and bolts in medical devices

devices can tip, fall or collapse if not properly maintained

human factors engineering

discipline of applying what is known about human capabilities and limitations to the design of products, processes, systems, and work environments

Medication errors from dose timing discrepancies in electronic medical records

discrepancies between dose timing intended by the provider and nursing workflow

RFID tags

embedded in patient identification bracelets, they can help with patient tracking during procedures and testing or function as part of the EHR to communicate pertinent information to clinicians at the bedside

right people

entire care team—including the patient

Infection risks from sterile processing

especially in medical and dental offices and ambulatory settings

right information

evidence-based guidance, response to clinical need

(1) the right patient (2) the right time and frequency of administration (3) the right dose (4) the right route (5) the right drug

five rights of medication administration:

right points in workflow

for decision making or action

Trigger algorithms

frequently applied to EMRs [electronic medical records] for automated surveillance, and increasingly to prospectively identify patients at risk

Healthcare technologies

frequently designed to improve patient safety, streamline work processes, and improve the quality and outcomes of healthcare delivery

computerized provider order entry (CPOE), automated dispensing machines, smart pump technologies for IV drug administration, and bar-code medication administration (BCMA)

frequently preceded the adoption of the EHR in many institutions because of the comparatively lower costs associated with implementing these technologies

RFID technologies:

have both supply chain and patient care applications to patient safety

Nurse informaticists and the IT team

must ensure that all systems are properly configured and maintained. They should routinely monitor and check these systems while making sure that their users are capable of using the systems accurately to avoid errors. A technology and its user can never be left to their own devices.

BCMA systems

help to ensure adherence to the five rights of medication administrationbar-code technology provides a system of checks and balances to ensure medication safety.

Missing implant data for MRI scan patients

implants can heat, move or malfunction when exposed to MRI's magnetic field

just culture

in which system or process issues that lead to unsafe behaviors and errors are addressed by changing practices or workflow processes and a clear message is communicated that reckless behaviors are not tolerated

Medications that are labeled individually by the in-house pharmacist

increase the potential for human error if the medication is given an incorrect bar code, such as one signifying a wrong dose or even the wrong medication.

Cybersecurity risks in the home health setting

increased vulnerabilities associated with remote monitoring and network connected medical technologies

Information scatter

information located in many different places and difficult to find

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

verification function (medication)

is computer based, and the medication order is electronically checked via the knowledge database. If the order is verified as safe and appropriate, the pharmacist proceeds to the dispensing process.

Point-of-care ultrasound

issues with user training, documentation and data archiving

Agency for Healthcare Research and Quality (AHRQ)

launch initiatives focused on safety research for patients.

Surgical robotic procedures

limited tactile feedback for forces exerted on tissue may result in injury

Patient Safety and Quality Improvement Act of 2005

mandated the creation of a national database of medical errors and funded several organizations to analyze these data with the goal of developing shared learning to prevent medical errors

caps of pill bottles

may contain RFID tags that monitor and collect data on when the bottle is opened or that contain flashing time reminders when a dose is due

Increasing demands on professionals in complex and fast-paced healthcare environments

may lead them to cut corners or develop workarounds that deviate from accepted and expected practice protocols. These deviations are not carried out deliberately to put patients at risk but rather are often practiced in the interest of saving time or preserving a usual workflow or because the organizational culture is such that risky behaviors are commonplace.

CPOE part of EHR with CDS system

medication order is electronically checked against specific data in the patient record to prevent errors, such as ordering a drug that might interact with a drug the patient is already taking, ordering a dose that is too large for the patient's weight, or ordering a drug that is contraindicated by the patient's allergy profile or renal function.

stand-alone CPOE system

medication orders are simply checked by the computer against the drug database to ensure that the dose and route specified in the order are appropriate for the medication chosen.

right intervention formats

order sets, flow-sheets, dashboards, patient lists

All the professionals are working toward the same goal:

positive patient outcomes

clinical decision support (CDS)

promote accurate medical diagnoses and suggest appropriate evidence-based medical and nursing interventions based on patient data

incident reporting software

reporting software specifically generating reports regarding incidents only

Smart pump: hard alarm

requires the clinician to reprogram the pump so that the dosing falls within the facility's IV administration guidelines for the drug to be infused

Hemodialysis risks with central venous catheters in the home health setting

risks include infection, clotting or hemorrhage

determines: -what happened -why did it happen -and how to prevent it from happening again

root-cause analysis ( U.S. Department of Veteran's Affairs National Center for Patient Safety)

CDS (Clinical Decision Support)

safe dosing parameters are provided by this when associated with a CPOE

CPOE:

solves the safety issues associated with poor handwriting and unclear or incomplete medication orders.

Surgical staplers

staple line failures or misapplication

ADC errors:

still possible when the override function is used to access medications from an ADC in emergent situations

Wearable technology

technologies 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. Although most of these technologies are designed for monitoring patients with chronic diseases, they also have safety implications because they help to identify early warning physiologic signs of impeding serious health events

Interdisciplinary collaboration and interprofessional collaboration

terms used to describe cooperative relationships among actively engaged professionals where healthcare decision-making is shared to combine their collective knowledge and skills to care for their patients

Medication errors

the most frequent and visible errors because the medication administration cycle has many poorly designed work processes with several opportunities for human error

WISH Patient Safety Forum

the patient safety premises that harms are inevitable, data silos (rather than shared data) are natural, and heroism is the norm

triggers

to detect adverse events, diagnostic errors, adverse drug events, hospital-acquired infections, and delays in diagnoses have been identified.

Joint commission:

to encourage reporting in a just culture, leadership must use accountability assessment tools to distinguish between human error and reckless behavior

Information overload

too much unnecessary information

3. Reckless behavior

total disregard for established policies and procedures

1. Human error

unintentional mistakes

Smart beds

which provide continuous rotation to prevent pressure ulcers, sense when a patient at risk for a fall leaves the bed, and continuously monitor vital signs, are also being implemented

To Err Is Human

widely credited for launching the current focus on patient safety in health care.

wireless chip on a disposable Band-Aid

with a 5- to 7-day battery, which was developed to monitor the patient's heart rate and electrocardiogram, blood glucose, blood pH, and blood pressure and allowed for the collection of important clinical data outside the hospital

2. Risky behavior

workarounds