Quality: Module One

Nursing (slides)*

Focus of nursing is on the human responses to actual or potential health problems, and advocacy for various clients. Nurses must possess: -the technical skills to manage equipment and perform procedures, -interpersonal skills to interact appropriately with people, and -cognitive skills to observe, recognize and collect data, analyze and interpret data and reach a reasonable conclusion that forms the basis of a decision. Nursing is an information intensive profession. The steps of utilizing information, applying knowledge to a problem, and acting with wisdom form the basis of nursing practice science. We acquire data and information in bits and pieces and then transform the information into knowledge.

knowledge

Holt - 2 competing traditions concerned this ultimate source of our knowledge empiricism: based on knowledge being derived from experiences or senses; do not recognize innate knowledge rationalism: some of our knowledge is derived from reason alone and that reason plays an important role in the acquisition of all of our knowledge; believe that reason is more essential in the acquisition of knowledge than the senses 3 sources of knowledge: 1) instinct, 2) reason, and 3) intuition. others perception and logic epistemology - the study of the nature and origin of knowledge - what it means to know

Nurse Informatics Education Organizations*

National League for nursing, quality and safety education for nurses QSEN, technology informatics guiding education reform initiative (tiger), nursing informatics deep dive by AACN focus on the need to integrate informatics competencies into nursing curriculum to prepare future nurses for the tasks of managing data information and knowledge, alleviating errors and promoting safety, supporting decision making and improving the quality of patient care

Bioethics (slides)*

defined as the study and formulation of healthcare ethics. takes on relevant ethical problems experienced by health care providers in the provision of care to individuals and groups. As technology advances increased, recognition and acknowledgment of rights and the needs of individuals and groups receiving this high tech care also increased.

Mouse

A mouse can come in a number of different configurations including a standard mechanical trackball serial mouse bus mouse PS/2 mouse USB connected mouse optical lens mouse cordless mouse and optomechanical mouse mice can have laser sensors, light-click buttons, gold-plated USB connectors, customization, adjustable weight, programmable macro commands, on the fly DPI switching The dots per inch dpi switch is an actual switch on the computers mouse that allows you to adjust the mouse a sensitivity to movement as in faster or slower mouse pointer speed's.

High Quality Data*

are relevant and accurately represent their corresponding concepts. Data are dirty when a database contains errors such as duplicate incomplete or outdated records. Characteristics include value, accessibility security timelessness timeliness accuracy relevancy completeness flexibility reliability objectivity utility transparency visibility and reproducibility

Principalism (slides)*

arose as societies became more heterogeneous and members began experiencing a diversity of incompatible beliefs and values. were expansive enough to be shared by all rational individuals, regardless of their background and individual beliefs. based on: Autonomy--free-will or agency, Beneficence--to do good, Nonmaleficence--not to harm, and Justice--social distribution of benefits and burdens.

Small Computer System Interface (SCSI)

provides the means to attach additional devices, such as scanners and extra hard drives, to the computer, printer port

Data Integrity (slides)*

Refers to whole, complete, correct, and consistent data Can be compromised through human error, viruses, worms, other bugs, hardware failures or crashes, transmission errors, and/or hackers entering the system

Quantum computing

quantum bits (qubits) a three-dimensional arrays of atoms in quantum states. A quantum computer is a proposed machine that is not based on the binary system but instead performs calculations based on the behavior of subatomic particles or qubits. If realized we will be able to execute millions of instructions per second MIPS due to the qubits existing in more than one state at a time or having the ability to simultaneously execut and process. Creation of qubits by David Weiss's research team

High Quality data (slides)*

Data that are relevant and accurately represent their corresponding concepts. Data are dirty when there are errors in the database such as duplicate, incomplete, or outdated records The data that we process into information must be of high quality and integrity to create meaning to inform our assessments and decision making.

Information Processing (slides)

Is the conversion of latent information into manifest information. Latent information is that which is not yet realized or apparent Manifest information is obvious or clearly apparent. Information science and computational tools are extremely important in enabling the processing of data, information, and knowledge in health care.

Voice controlled technology

Vocera developed the Vocera B3000n Communication Badge which is a lightweight, voice-controlled, wearable devices that enables instant two-way or one to many conversations using intuitive and simple commands. The Vocera badge is widely used by mobile workers who need wearable devices that provide the convenience and experience of being able to respond to calls without pressing a button. permit nurses to use wireless, hands-free devices to communication with one another and to record data

Ethics (slides)*

a process of systematically examining varying viewpoints related to moral questions of right and wrong. Regardless of the theoretical definition, common characteristics regarding ethics are its dialectical, goal-oriented approach to answering questions that have the potential of multiple acceptable answers.

Haptic technology

brings the sense of touch to digital content. combined with a visual display can be used to prepare users for tasks necessitating hand-eye coordination such a surgical procedures

Data & Information (slide)*

data: raw facts information: Processed data that has meaning Information is data that is processed using knowledge. In order for information to be valuable or meaningful, it must be accessible, accurate, timely, complete, cost effective, flexible, reliable, relevant, simple, verifiable, and secure

Feedback

or responses are reactions to the inputting processing and outputs. in ISs feedback refers to information from the system that is used to make modifications in the input processing actions or outputs

Data Integrity*

refers to whole complete correct and consistent data. can be compromised through human error viruses worms or other computer bugs hardware failures or crashes transmission errors or hackers entering the system. Information technologies help to decrease these errors by putting into place safeguards such as backing up files on a routine basis error detection for transmissions and user interfaces that help people enter the data correctly. Human error: incorrect data entry and spelling errors. malware: viruses worms spam ransomware. machine error: hardware failure software crashes. transmission errors: connectivity issues data corruption and lost data

Five Rights of Knowledge

the right information accessible by the right people in the right setting applied the right way at the right time

Beyond Clinical Nursing Practice (slides)

In order for nurse educators to be effective, they must be in the habit of constantly building and rebuilding their foundation of knowledge about nursing science. Nurse researchers must acquire and process new knowledge as they design and conduct their research studies.

Use of Knowledge (slides)

Individuals have an amazing ability to manage knowledge. This ability is learned and honed from birth. We experience our environment and learn by acquiring, processing, generating and disseminating knowledge. All nurses have the opportunity to be involved in the formal dissemination of knowledge via their participation in professional conferences either as presenters or attendees. All nurses, regardless of the practice arena, must use informatics and technology to inform and support that practice.

Foundation of Knowledge Model (slides)

Organizing conceptual framework for text Helps to explain the ties between nursing science and informatics and knowledge Informatics is viewed as a tool for founding knowledge We will also introduce the Foundation of Knowledge Model © 2007 as the organizing conceptual framework of this text, and tie the model to nursing science and the practice of nursing informatics. The American Nurses' Association (2003) defines nursing in this way: "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations."

Computer based information systems (CBIS)

are combinations of hardware software and telecommunications networks that people build and use to collect create and distribute useful data typically in organizational settings

Cognitive science**

deals with how the human mind functions. This science encompasses how people think understand remember synthesize and access stored information and knowledge.

Foundation of Knowledge Model

knowledge acquisition knowledge processing knowledge generation and knowledge dissemination

Important Stuff from Video

more than 100000 americans die bc of healthcare harm since 1999 doubles if you include infections patients get from hospitals chasing zero - getting these numbers down to 0 twins - staph infection - back to hospital, overdose twice, 1000x the amount of heparin they should have receive - close to dying mayo clinic - chasing 0 role models developed cleaning checklist - high contact surfaces, using culture methods from other industries pyxis - enter patient number and name, pharmacists barcode it jaundice off the charts - highest ever seen, treated with phototherapy, arching backwards, classic signs of brain damage from jaundice - now has kernicterus, cerebral palsy, hearing impaired, speech impaired denial and lack of knowledge of performance weapons against health care harm are leadership, safe practices and technology great leaders take risks, they confront their fear to drive adoption of best practices and they invest in technologies that make it easier to be safe institute for healthcare improvements - 100000 lives campaign - key national quality forum safe practices working with TMIT to adopt safety vials look much a like - 1000x more, 2x over 8 hr period - similar labeling and size. labeling on vials have dramatically changed since then. surgery for sleep apnea - home from hospital everything was fine. 4pm had pain, gave him pain medication. fell asleep, woke up with chest pain. last time he saw him alive. months and months without answers from medical examiner. forced to seek legal help. only given 2-3 pages for medical records - don't keep anesthesia records and nursing notes. got complete set of medical records with legal help. hospitals should reach out to families after an adverse event. husband had pain base of skull and cerv spine - remove tumor, sent to pathology, benign tumor, 6 months later, husband was in pain again. another MRI - tumor as large as fist. original path report said cancer. husband died. got filed in chart without anyone seeing it except the pathologist. underwent five more surgeries, removed spine, became disabled, using a walker. 1.5 year of treatment, came back explosively, paralyzed waist down, days to live fear - if we make mistakes not to come forward, punished if acknowledge mistakes - should not be criminalized, just going to alienate worked a double shift, busy. slept in patient room bc had to be back next day. 16 year old to deliver baby - break her water, start pitocin, deliver baby, followed guidelines for epidural injection, prepared anethestic medication and same time she had antibiotic ready to go. did IV. hooked up wrong medication to her IV - gave her epidural through IV instead of antibiotic. patient flat lined. she was fired and criminally indighted- had to plead a misdemeanor to avoid prison, lost her license bc she was presumed to be incompetent - no evidence that she was incompetent works for TMIT now to improve hospitals care of a caregiver - pharmacist convicted on involuntary manslaughter after a 2yo received a saline injection of 20x time the intended concentration. pharm tech accidentally mixed the saline solution incorrectly and signed off on her work. killed the patient. first and second degree burns from climbing into a hot bath - death result from total breakdown of the system - impacted 2000 hospital, josey king story start with engaged leaders, practices that work, implement the practices with great technologies that make it safe empower the staff - 2 months listening to 250 people on what can do better and game up with 72 recommendations share rounds - giving report in front of the patient IHI open school - health care students into the safety game. check a box save a life. surgical checklist WHO check list combined with regulatory requirements - use it in every operating room in america checklists help make things simple, predictable, standardized, they enhance communication don't miss an element of care, provide safe care, and do it the same way overtime health care - autonomous culture, grossly under standardized barcode technology - same more lives, bar code on med matches barcode profiled for that patient, does the safety check of those 5 rights - the right medication, the right dose, the right time, the right patient and the right route. doesn't do critical thinking for the nurse. Smart pump - has drug library, need to know how to give drugs, follow policy and procdure, safety check, safely give the med, this is rate and how fast you want to run it. scan patient, med, and pump chlorhexidine with alcohol prep - type 2 wounds, more common types of abdominal surgery and lung surgery, reduced rate of infections by 40%. save 2-4k per patient. computer prescriber order entry (CPOE) - automatically check for accurate dosage, allergies and drug interactions when prescribing medications for their patients. May not always be implemented well - can be less effective and even cause unintended harm. cpoe flight simulator - lets hospitals verify their performance before they use it on real patients, lets hospitals get a sense of how good the checks for problems are around medications when a doctor is ordering meds. develop a set of orders 4 meds that have harmed patients. look to see how often computer would warn about those errors simulation is the future of medical care - surgical operations to use of sophisticated devices. making sure that the CPOE works as we expect it to, teamwork in emergencies, computers, lab work automated infection identification and mitigation systems - AIMS - used to identify and prevent the impact of infections using computer systems. who - formed a group of patients to improve health care system partnerships with patients and families, consumers to become advocates in ownership of their own health, healthcare, and do hold us accountable the quaid foundation has merged into TMIT - save lives, save money and bring value into the communities we serve

Peripheral component interconnection bus

this component is important for connecting additional plug-in components to the computer. It uses a series of slots on the motherboard to allow peripheral component interconnection PCI card plug-in

New Challenges (slides)*

Consider that patients and health care providers no longer have to be in the same place for a quality interaction. How then does one deal with licensing issues if the electronic consultation takes place across a state line? Consider the ethical issues created by genomic databases or by sharing information in a health information exchange to promote population health. Does public good outweigh individual interests in data collection and data mining?

ANA Definition of Nursing (slides)*

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

Information Science (slides)*

Science of information, studying the application and usage of information and knowledge in organizations and the interfacings or interaction between people, organizations, and information systems Information science enables the processing of information is a multidisciplinary science that involves aspects from computer science, cognitive science, social science, communication science, and library science to deal with obtaining, gathering, organizing, manipulating, managing, storing, retrieving, recapturing, disposing of, distributing, or broadcasting information. Information science studies everything that deals with information and can be defined as the study of information systems. This science originated as a subdiscipline of computer science, in an attempt to understand and rationalize the management of technology within organizations.

Technology Developments Create Ethics Concerns (slides)*

Smartphone apps to direct, interact with and monitor patient status and behaviors Google glass for 'secretive' photos and videos Social media such as Facebook, Twitter, LinkedIn, and YouTube Mobile device use by healthcare providers

Theoretical Approaches to Healthcare Ethics(slides)*

Theoretical approaches to healthcare ethics have evolved in response to societal changes. The Hippocratic tradition emerged from relatively homogenous societies where beliefs were similar and the majority of societal members shared common values. Each method reflects an important aspect of ethical experience, adds to the others, and enriches the ethical imagination. Diverse ethical insights can be integrated to support a particular bioethical decision, and that decision can be understood as a new, ethical whole.

Care Ethics Model*

is responsiveness to the needs of others that dictates providing care preventing harm and maintaining relationships. Carol Gilligan's in a different voice established care ethics as a major new perspective in contemporary moral and political discourse. Benjamin and Curtis base their framework on care ethics; they propose that critical reflection and inquiry in ethics involves the complex interplay of a variety of human faculties ranging from empathy and moral imagination on the one hand to analytic precision and careful reasoning on the other. Less stringently guided by rules but rather focus on the needs of others and the individual's responsibility to meet those needs. Emphasizes the personal part of an interdependent relationship that affects how decisions are made. The specifics situation and context in which the person is embedded become a part of the decision-making process.

CD-ROM

uses a laser diode to emit an infrared light beam that reflects onto a track on the CD using a mirror positioned by a monitor. The light reflected on the disk is directed by a system of lenses to a photodetector that converts the light pulses into an electrical signal; the signal is then decoded by the drive electronics to the motherboard

ethical dilemmas and morals (slides)*

Ethical dilemmas arise when moral issues raise questions that cannot be answered with a simple, clearly defined rule, fact or authoritative view. Moral dilemmas occur when some evidence indicates that an act is morally right and some evidence indicates the act is morally wrong; yet the evidence on both sides is inconclusive; or an individual believes that on moral grounds, he or she cannot commit an act (Beauchamp and Childress, p. 11).

Dennis Quaid Video Transcript

Dennis Quaid VO: Most of us think of hospitals as cathedrals of healing and hope and we stand in awe of the doctors and nurses who work in them, as the architects of miracles. But even the best hospitals can be dangerous places with unknown hazards that can cause catastrophic harm. They are the battlefield of a war with an invisible enemy that never sleeps. Failing support systems that can't keep up. Host: I'm Dennis Quaid. I found out about healthcare harm because it happened to my family. Host: Since 1999 we've known that more than one hundred thousand Americans die every year because of healthcare harm, every year. Host: That's the equivalent of more than ten jumbo jet airliners crashing every single week. And that number doubles if you include infections patients get from hospitals. Dennis Quaid Voice Over: The shear number of deaths is shocking, however what's even more shocking is that it is possible to bring this to almost zero. So why isn't it happening? You will meet just a few of the many leaders who are making it happen. Host: They call it "chasing zero" and they are preventing the enemy from shattering other families' lives the way it almost shattered mine. Dennis interview: Our twins were born happy and healthy and so were we. We had just got them home and it wound up that they had a staff infection. They had to go back into the hospital. They were overdosed twice with a thousand times the amount of Heparin than they should've received. Our little twins were the victims of preventable harm. They came very very close to dying. I've been in the hospital in my life. I had never given a thought to my own safety about being there. I always trust the doctors and the nurses and they knew what they were doing and they never make mistakes but this is preventable error. That was a wake-up call for my wife and I to try to do as much as we could to try to make sure this doesn't happen to other families. CSPAN footage of Dennis testifying to Congress: "When the twins were in the hospital, they had made it, it made me feel that they had survived for a reason. That um, first off, I really thank God that they pulled through. But they survived for a reason, that they were maybe going to change the world in a little way that might wind up saving more lives." Dennis Quaid Voice Over: I was looking for a way to help prevent harm to other families and children when I met Dr. Charles Denham, the leader of TMIT a medical research organization in patient safety. He introduced me to the heroes in the movement and I have found the role I can play. I've joined the army of those who are chasing zero harm together. Chuck: "These are the group of leaders you can ask to step up." Dennis: "I'll tell you what I'm excited about. I'm excited to be working with people like you, Chuck, because you've taught me quite a lot." Chuck: "We are so grateful to have somebody that's a voice." Dennis: "Well, thank you." Dennis Quaid Voice Over: Fear is a major barrier to action. But the great ones like the Mayo Clinic are ever vigilant and humble champions of high performance. They are just one of the Chasing Zero role models. Steve Swenson: "I'll never forget the day that we learned of the Quaid accident. A cold chill came over me when I asked myself could this happen at the Mayo Clinic? The answer was yes." Dennis Quaid Voice Over: The collaborative empowering culture of Mayo allows nurses to redesign their workflow; they adopt safe practices, and even allow their cleaning staff to get involved. They developed their own new cleaning checklists of high contact surfaces to prevent infections using culture methods from other industries. Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 2 of 12 Cleaning Lady at Mayo: "If we can help them not to get more infection, we're not just we are not just cleaning rooms, we are saving lives." Steve Swenson: "This is a Pyxis medication dispensing unit. It's another system safety net that we have to protect patients from the frailties of competent human beings. Our nurses enter the identification number and the patient name to make sure that the right medication is taken out of the Pyxis unit and the pharmacists put the medication in only after they've bar-coded it to make sure it's the right medication for the right patient at the right dose." Dennis Quaid Voice Over: Despite the efforts of places like the Mayo Clinic, healthcare harm still occurs in many hospitals. Sue Sheridan is a great example of someone who has turned her family's tragedy into triumph by putting aside her anger and resentment...moving forward to make things better. Sue Sheridan: "In 1995 my son Cal was born a healthy baby, a normal delivery. "When we were home he started to change before our eyes. And eventually Cal was readmitted to the hospital. It was discovered that his jaundice was - I remember the nurse's term- off the charts. One of the highest they'd ever seen at the hospital. They treated Cal's jaundice with traditional treatment with phototherapy. However, on the second day he was there, about 24 hours, Cal started arching backwards. They were classic signs of the onset of brain damage from jaundice. Cal now has a condition called Kernicterus. It is brain damage from jaundice. And he has significant cerebral palsy, he's hearing impaired, he's speech impaired, um very bright very witty, but his lifelong challenges were totally preventable. Ajish Jah: "We just finished a survey, we surveyed over a thousand hospitals across the country. And when you look at the bottom, the worst performing hospitals in America, not a single board chair from any of those hospitals, not one thought they were below average. These are hospitals that are at the very bottom of performance. They are terrible quality and yet most thought they were better than average, a few thought they were about average but not a single one thought they were below average. It's a level of denial and a lack of knowledge about their own performance that I think is shocking." Dennis Quaid Voice Over: Business performance guru Jim Collins has documented how even the Mighty Fall in his recent best seller. The principles are frighteningly applicable to hospitals. Jim Collins: "How do institutions fall? How do they go from great performance to good to mediocre to bad and maybe even irrelevant? What we found is it is actually a little bit like a staged disease. That there's...that you go through the early stages of the disease, still looking healthy on the outside. You can more easily deny that you're sick because you look healthy. Now, if you look inside, you might not look so healthy. But, if you look on the outside and you can still say, 'See? We're still doing well." Dennis Quaid Voice Over: If our healthcare leaders can get through their denial about their failing systems, it becomes a David and Goliath story. Goliath is fear - fear of shame, fear of malpractice, and fear of cost. To win the war on harm we must activate the inner David in our hospital leaders. They will find that Goliath is not as big as they think he is. The weapons against healthcare harm are leadership, safe practices, and technology. Great leaders take risks. They confront their fear to drive adoption of best practices and they invest in technologies that make it easier to be safe. Has this been done before? Do we have role models? Absolutely! Many agree that the Institute for Healthcare Improvement's 100 Thousand Lives Campaign, led by Dr. Don Berwick, ignited the passions of America's healthcare leaders to save lives and put us on a path to zero harm. Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 3 of 12 Chuck: "Don, take me back to when you stepped up to the podium and announced the 100,000 Lives Campaign. Were you scared? What was it like?" Don Berwick: "Well, when we in the Institute for Healthcare Improvement thought of the 100,000 Lives Campaign, we knew we were going out on thin ice. And I was scared. I stood in front of 5,000 people at IHI's annual National Forum on Quality in Healthcare and I was going to lay out this challenge." "Here's the number, 100,000 and here's the time, June 14, 2006, 9 AM." "I really didn't know what the reactions would be. Denial, anger, silence. Of course, what happened was just the opposite. We got more involvement and more enthusiasm and more buoyancy in the pursuit of healthcare improvement than I had experienced in my entire career." Chuck: "What was it like to realize that the 100,000 Lives Campaign, then, was achieved? The goal was met?" Don Berwick: "The biggest surprise in the 100,000 Lives Campaign and the 5,000,000 Lives Campaign that followed it was the reservoir, the immense reservoir of good will, commitment, courage, intention in the healthcare workforce. Doctors and nurses, technicians, pharmacists, managers all over the nation...eventually, all over the world, really wanting to make care safer and better, not angry that we were challenging them to do it, but grateful that we would...we would put a stake in the ground and...and that we would say let's go do this. That...that energy, it still awes me." Dennis VO Many of the main elements to the 100 Thousand Lives Campaign have become key National Quality Forum Safe Practices. A leader's blue print to chasing zero. Janet Corrigan: "The safe practices are a road map. There's no need for every hospital to reinvent the wheel. These are practices that have been proven. There's a strong evidence base. They can be implemented in every single hospital immediately." Dennis VO Leading organizations such as the Mayo Clinic, Cleveland Clinic, Vanderbilt, Catholic Healthcare Partners, and Brigham and Woman's Hospital are working with TMIT to validate the financial business case for adoption of the safe practices so that leaders will "Greenlight" investment in safety. David Bates: "For boards and administrators, I think the Green Light approach will help them justify the hard decisions that need to be made about investing in changes that are going to tangibly improve safety." Don Berwick: "We have some great action lists for leaders, like the National Quality Forum Safe Practices. That is, we know what to implement. So far, we're approaching that as a matter of volunteerism. We're saying, please, do this. We know it works, saves lives, reduces injuries. Ultimately, we're going to have to mature, I think, to the point where a safe practice that's well known is no longer an optional matter. You have to be safe because we know how to do it. We owe it to our patients." Dennis interview: "It's an honor really to be a part of authoring the NQF Safe Practices. What I really appreciate is that they are involving patients because patients are a part of the healthcare team. An often-unused one. So it's really great that they are involving patients in the process." CSPAN footage of Dennis testifying before Congress: Congressman Henry Waxman: "Mr. Quaid, to understand what happened to your twins you had on the screen the two vials, I do have them right here. They look very, very much alike. The one that was 1,000 times more was the one administered to your children, is that right?" Dennis: "Yes sir, not once but twice over an 8 hour period." Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 4 of 12 Waxman: "Not once but twice?" Dennis: "Now how could this have happened? Well, the answer became very clear to us after talking to doctors and nurses and doing a little bit of research on our own. The ten units of Heplock and ten thousand unit of Heparin are deadly similar in their labeling and size. The ten thousand unit of Heparin is dark blue and the ten-unit bottle is light blue. And if the bottles are slightly rotated as they often are when they are stored. They are virtually indistinguishable. Since this brush with tragedy my wife and I have found out that such errors are unfortunately all too common. Dennis Quaid Voice Over: Since our accident the labeling on the vials has dramatically changed. Our twins, Zoe Grace and T. Boone Quaid are already protecting other kids and saving lives. While my wife Kimberly and I have been on this journey we've had the privilege of learning about many other families who have gone through similar tragedies. Steve Rel: "Braxton always had a smile and he just, you know, he loved life. He was putting in the time and the dedication... he spent hours at the stairs um 'Dad, throw some pucks at me, dad'. You know, I think the difference between an athlete and a professional athlete is their heart and their dedication and I think Braxton could've been one to take it real far." Chuck: "Now let's go back to the beginning. Braxton needed the surgery for sleep apnea, was Braxton worried?" Steve Rel: "He always put on a tough face but yeah, he was concerned. He was very worried." Chuck: "What did you tell him?" Steve: "That he was gonna be okay. And it wasn't true." Steve: "We brought Brax home from the hospital and everything seemed fine. You know, he wasn't complaining much of pain. He was resting and we watched some TV. We sat with him. Watched some cartoons. At about 4 o'clock he said dad, I'm hurting. So I gave him his pain medicine. And everything seemed all right. He fell asleep which seemed normal to me and he woke up at 7:30 and he said dad my chest hurts. You know, I'll never forget that I sat and just comforted him and I asked him Braxton are you all right? Are you in pain? Do you need something for pain? Do you need something for pain? And he said, no dad I'm fine. That's the last time I saw him alive. We went months and months without any word from the medical examiner and all we wanted to know was what happened to our son. " Dennis Quaid Voice Over: The Rels went for 4 months without answers and then they were forced to seek legal help. The system failed them. 13 months after Braxton's death all they had was an autopsy report sent in the mail. Steve Rel: "When I went to get the medical records I was given two or three pages and I was told that they don't keep anesthesia records and nursing notes. And it just didn't seem right to me so I talked to some experts and was given some advice on how to get the complete set of medical records. Which I did. You know, it really erodes your trust and it makes you fearful. You think you would have answers right away when something adverse happens to your loved one. It's been 13 months and we still don't have all the answers." Chuck: "So you don't have closure?" Steve Rel: "No closure at all." Interview of Dennis: "A lot of times I think the lawyers get involved, the hospital lawyers get involved and the focus seems to be on risk management after an accident occurs. Not to say that they weren't doing everything they could to right the situation but as a human being I felt that the last thing I want to do is focus on legal issues. And somebody's liability." Steve Rel: "The last thing we wanted was to hire an attorney. Just to get the answers that we should've had all along." Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 5 of 12 "The NQF Safe Practices states that hospitals and caregivers should reach out to the family within 24 hours of an adverse event. Without any type of communication it makes us feel that Braxton didn't mean anything to anybody but us. You have to communicate, you know, it's the most important thing there is." Dennis interview: "Its understandable that a hospital reacts the way that they do because it is a business and there is liability involved and yes, they have to protect themselves and protect that entity but what happens in the end is that a lot of times the problem ends up not getting fixed because a lot of things get swept under the carpet. They don't want people to talk. They don't want the nurses to talk. They don't want the staff to really talk. So the investigation into what really happened is stifled." Dennis Quaid Voice Over: For Sue, preventable harm struck her family not once but twice. Sue Sheridan: "Shortly after Cal's injury, my husband Pat had a pain at the base of his skull, his cervical spine. They removed, actually a tumor from the base of his skull. Sent it to pathology. The surgeon came out when my husband was in the operating room and he shared with me that it was a benign tumor And six months later my husband was in pain again. We got another MRI and it was discovered that Pat had a mass the size of the surgeon's fist. Dennis Quaid Voice Over: The final pathology report from his initial surgery indicated that Pat had cancer. This miss-placed path report was yet another error that shattered the future for the Sheridan family ending Pat's life prematurely. Sue Sheridan: We to this day still don't know what happened to it. It appears that it got filed in my husband's chart without anybody seeing it except the pathologist." Sue Sheridan: "Pat underwent 5 more surgeries. They basically removed his spine. He became disabled. So I had a son using a walker and a husband using a walker. But after about a year and a half of treatment, Pat's cancer came back explosively. And he woke up paralyzed one day from his waist down. "Pat had always told me that if he was going to die from his cancer that he wanted to die family and friends and a bunch of really good wine. And he, after a long, long pause said I want to go to Disney World. I want to watch my kids and my family have the time of their lives. And so, after I collected myself, I picked up the phone and I called Disney World. And within 4 days 53 of us flew to Disney. They put the kids in parades. They sent up Minnie, Mickey, Pluto. It was a truly a celebration. On the third day, Pat died at Disney World." Carolyn Clancy: "One of the biggest barriers to getting to safe care all the time, everywhere, is fear. We're trained if we make mistakes not to come forward, that this is something to hide and feel badly about. And sometimes people are punished when they acknowledge mistakes, a very powerful lesson gets learned immediately when that happens." Dennis interview: "Kimberly and I tried to put ourselves in the nurse's shoes. I'm sure no one wanted to harm our kids. Human error is a part of the system. They should not be criminalized. All it's going to do is alienate the very people that we are trying to bring in to help make things better. And they shouldn't be punished." Julie Thao: "I wanted to be a nurse and with babies since I was a little girl. In 1990 I graduated from nursing school. I had 4 little babies. Until about 4 years ago when this happened my life was full of babies." "On the 4th of July I worked a double shift and we were busy and it was almost 1 AM before I was able to kind of wind down and I was too tired to drive home. And I lived a long way from the hospital I decided I was too tired to drive home and I needed to be back in a few hours to do the day shift I was scheduled for and so I laid down in a patient room in a patient bed and tried to sleep. And got up to start the next day. And at 9 o'clock I met the patient. She was just a young 16 year old girl and she was so scared." "The plan was that they were going to break her water and start some pitocin and she was going to deliver her baby." Dennis Quaid Voice Over: Julie followed nursing unit guidelines designed to improve readiness of patients for anesthesiologists to give an epidural injection. She adhered to a checklist of the guidelines and prepared the anesthetic medication at the same time that she had antibiotic medication ready to go. A number of systems flaws led to Julie's absolutely predictable human error. Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 6 of 12 Julie Thao: "So I got her IV, her antibiotic and her epidural bag. Both bags had ends that received IV tubing. I had her antibiotic in my hand I knew that. But I didn't have her antibiotic in my hand; I had her epidural medication in my hand. And after it started running I heard a sound and turned to her bed and she was already arresting." "People came to her room immediately, many many many people. Dozens of people who are familiar with both those medications that we used. Everyone saw that hanging there. In fact I said, I just hung this antibiotic and I think she's reacting to the penicillin." "And then somebody cleaning the room found the bag and brought it to me and they were crying and put it in my hands. And it didn't make sense for a while and I kept looking and it just crumbled." Dennis Quaid Voice Over: Julie administered the wrong medication. Fatigue, identical medication tubing connectors, similar IV fluid bags, and a sub-optimal bar code process, all spelled death for the young mother. The hospital fired Julie. She was criminally indicted. As a single mother of 4 and with no resources to defend herself, she had to plead a misdemeanor to avoid prison. What happened to her led to the development of the new National Quality Forum Safe Practice called Care of the Caregiver. Lucian Leape: "The Julie Thao story because she was hung out to dry for making a mistake which was clearly caused by a whole host of very bad systems. She was truly the second victim in two ways, she was the victim of bad systems as well as being emotionally a second victim. She was devastated by her error as anyone would be but in addition she was the person who was the victim of these bad systems. And the lesson, I think is, not just that hospitals need to be responsible for their systems and fix them which is clearly what they ought to do but there is a second lesson here and that is Julie Thao was fired, she was indicted, she lost her license because she was presumed to be incompetent. There's no evidence that she was incompetent. No evidence was ever produced that she was incompetent." Dennis Quaid Voice Over: Eric Cropp, is a hospital pharmacist convicted of involuntary manslaughter after a two year old girl received a fatal injection of saline solution more than 20 times the intended concentration. A pharmacy technician working under Eric on a very busy day accidently mixed the clear saline solution incorrectly. By signing off on her work, Eric sealed his fate. Eric Cropp: "I wish I could change it. I wish I could change places with Emily. I wish I was the one that was dead. And it's just hard because I didn't have anybody there for me either. And it hurts." Lucian Leape: "I think criminalization is a terrible thing because the examples that I know. Fortunately there have only been a few, but in every case there were obvious explanations for why a mistake happened and those explanations all have to do with the systems they were working in." Don Berwick: "We now have a safe practice around care of the caregiver, which defined good ways to deal with the people involved at the providing end of care...involved in an injury. They need help, they need healing, they need support. And you need them. Sometimes, the best knowledge you could ever get, that will allow you to redesign the care system for which you are responsible, will come from the very people who've been trapped in this spider web of cause and effect that's led to the injury." Dennis Quaid Voice Over: 3 years after the death of Julie's patient, the hospital published an independent study revealing that multiple systems issues contributed to setting up Julie's error. An honest mistake, anyone could have made. Never shirking her accountability for causing a death, Julie has moved on as a TMIT patient safety fellow to help save other lives. She is helping measure lives saved and dollars invested in safety from the impact of video stories now being used in thousands of hospitals, deployed by TMIT. One of many video stories is about a little girl named Josie King. Sorrel King: I would like to share my story with you. I do this with the hope that what I'm about to tell you will make a difference in how you care for your patients and how strongly committed you and your hospital are to patient safety. Josie was admitted after suffering first and second degree burns from climbing into a hot bath. Josie's death was not the fault of one doctor or one nurse. It was the result of a total breakdown in the system." Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 7 of 12 Dennis Quaid Voice Over: The power of stories is incredible. In Story Power: The Secret Weapon—our article targeting healthcare leaders—we share some of the secrets of the power of connecting the head to the heart to prompt action. In it we present the preliminary results of the Josie King story and its impact on 2000 hospitals. It revealed that the majority of users have seen lives saved and money invested as a direct result of viewing it. Dennis interview: "Well the battle is one little life at a time I think. That's what the battle is. One mistake at a time, one little life at a time. And the war is really...the end result of the war would be taking medical errors down to zero." Dennis Quaid Voice Over: So you need three things. You have to start with engaged leaders. Then practices that work. Then if you implement the practices with great technologies that make it easier to be safe, you have the winning combination in the war on preventable harm. Here lies the sweet spot of high performance and safe care. Many hospitals are getting extraordinary results from ordinary things they already have today. Bill Rupp: "My biggest lesson has been to empower the staff. We spent two months listening to 250 people in this organization about what we could do to make it better. We came up with a list of 72 recommendations. Seventy-one of those came from the staff. That's what we're implementing, and that's why things are getting better." Dennis Quaid Voice Over: An example of staff led innovations is Share Rounds developed at the Mayo Clinic in Rochester, Minnesota which helps nurses include the patients in the process of passing on information during shift change, making the patient and family part of their own safety net. Nurse: "It's really hard to understand how your day is gonna go without visualizing a patient. We used to give report right out at the nurse's station or in the back room. The nurse would sometimes write report or tell you in person, but you can't really assess a person or be prepared for your day until you actually see the patient in person." Nurse: "The first thing we do is we can get an overall picture of how the patient is doing." Nurse: "You can see that he's doing well, his pain is under control, and maybe address any needs right away." Nurse: "I'll be leaving now, but Amanda's gonna take great care of you tonight." Nurse: "This way before I leave, the patient is comfortable with who his next nurse is." Patient: "I feel more involved. Makes me feel reassured, that the nurse coming on knows exactly what's going on with me, and they are in coordination." Patient Wife: "I can ask questions as well, and if there's something that I'm concerned about or I am thinking about, I can bring it up because the nurse that's going off knows perhaps something that we've discussed earlier and, and then that sort of reminds all of us to pass it on to the nurse that's coming on." Nurse: "No problem. Have a good evening. She'll take good care of you." Nurse: "I definitely think that this could be done at any hospital." Nurse: "Knock, knock. Good morning Ms. Hunt." Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 8 of 12 Nurse: "Hi there. This is Casey. She's gonna be your nurse this morning from 7:00 to 3:00." Nurse: "Just by changing the routine a little bit, and that might be a bit of an adjustment, it actually is just that simple. It's just bringing it in to the patient." Nurse: "And then her IV was changed yesterday, so that's good." Nurse: "I don't just think it should be done, I think it needs to be done. I mean it provides for the safest way to care for the patient." Dennis Quaid Voice Over: Another great, cost free initiative is the IHI Open School, which puts healthcare students into the safety game - literally thousands are joining the action. Dr. Don Berwick: "Check a box, safe a life. That's a program devised by medical students, nursing students and pharmacy students who realized that students, when they're in training in hospitals, can introduce the surgical checklist as sort of change agents from the inside. They calculated, the medical students calculated that a medical student, during their surgical clerkship, when they're learning surgery, is involved in enough operations that if you do the math, if they could get the checklist used in all the operations they're involved in, one life would be saved. Check a box, save a life." Charles Denham: "Dennis are you surprised that we're just starting to use checklists in healthcare? You're an experienced pilot you know the value of a checklists." Dennis: I can't believe it to tell you the truth that it's not there. How much does this cost?" Chuck: "Exactly." Dennis: "It's the most important piece of equipment really on the airplane." Charolette Guglielmi: "We're taking the World Health Organization checklist and we're combining it with the regulatory requirements, so that we can use it in every operating room in America. Checklists help make things simple, predictable, standardized. They enhance communication, just like they do in airplanes. Dennis: "We were just going through the checklist right, you were calling it out and we got to Beacon and I said off. What does the checklist say? Chuck: "On." Dennis: "On. So we missed that." Chuck: "We missed something on the checklist." Dennis: "Yeah, that's why checklists are important. But they always have to be backed up by humans." Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 9 of 12 Chuck: "Exactly." Dennis: "It's human error." Chuck: "Good point." Charolette Guglielmi: "We're using checklists in our operating rooms so that we can make sure that we don't miss an element of care, that we provide safe care and that we do it the same way every time." Chuck: "I feel like we haven't even touched what checklists could do for us in medicine, is that a fair statement or is that unfair?" Peter Pronovost: "No it's absolutely a fair statement Chuck. Healthcare is grossly under-standardized, and checklists are a tool to help us do our work, but they standardize processes. In healthcare we have a very autonomous culture that is grossly under-standardized. We've got to make sure we have a checklist and ensure it's done on every patient, every day, all the time." Michael Henderson: "When I see when I come down is we're functioning much more as a team in the operating rooms and I think that's huge." Allan Sipperstein: "If something's not working quite right it can be reported and acted upon before the next case." Michael Henderson: "Yeah, the checklist has been a real way of getting to that. I think one of the biggest patient safety things we've certainly seen in the ORs in my lifetime. I think it's fantastic. Chuck: "Avionics Master." Dennis: "Avionics Master is on." Chuck: "Emergency Lights." Dennis: "Emergency Lights on." Chuck: "Beacon." Dennis: "Beacon on." Dennis Quaid Voice Over: Technologies make it easier to be safe. Once you have engaged leaders and staff, open to improve their own practices, they deliver great impact. Nurse: Currently there's just a handful of hospitals within the nation that have the bar code technology. If they did have this technology in place, I do believe that it would save more lives. I'm just going to double check here. The software matches the bar code on the medication to the bar code profiled for the patient, but does that safety check of the five rights: The right medication, the right dose, the right time, the right patient and the right route. It does not do the critical thinking for the nurse; however, it does ensure that those five Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 10 of 12 things are matching for the medication and for the patient. Nurse: Before we had the smart pump we had a pump that looked similar but did not have a drug library. We'd go on the information we have on paper essentially, as far as how to give a medication. Now that we have the smart pump, we're still responsible for knowing how to give these drugs, to follow the policy and procedure. However this is a double check for us. We're able to program the pumps, to know this is the way to safely give this medication. This is the rate, this is how fast you want to run it. You're going to use the bar coding system to scan your medication, scan your patient. Once you get all your checks and everything matched up, you're then ready to hang your med. At the end of the day this is what double-checks your work and covers you as a nurse when you're hanging medications. Dennis Quaid Voice Over: The Computer Prescriber Order Entry or CPOE allows doctors and other caregivers to automatically check for accurate dosage, allergies and drug interactions when prescribing medications for their patients. Without CPOE this is a manual paper process with no safety net. This sophisticated technology, however may not always be implemented well and can be less effective or even cause unintended harm. A real breakthrough, developed by leading experts is The CPOE Flight Simulator that allows hospitals to verify their performance before they use it on real patients. Charles Denham: You and I have had the wonderful privilege to work together with doctors like Dr. David Classen and others on the CPOE flight simulator. Just to put it in layman's terms, what is it, and what's the value? David Bates: "The flight simulator basically lets hospitals get a sense of how good the checks for problems are around medications when a doctor is ordering a medication. And what we did was to develop a set of orders for medications that have harmed patients, and looked to see how often the computer would warn about those errors." Carolyn Clancy: "There's no question that simulation is the future of medical care. I think it's the future in everything from surgical operations to the use of sophisticated devices to actually making sure that the computerized order entry system works as we expected to it. You can't know until you check it and better to know ahead of time then to find out that our expectations didn't come about. For everything from surgical operations to team work in emergencies to the use of very sophisticated devices, to the use of computers effectively, simulation and practice and rehearsal and getting it right in the laboratory, so to speak, will definitely be the way we move forward. This is going to be transformative in terms of getting to safer care." Dennis Quaid Voice Over: One of the most powerful innovations in healthcare are Automated Infection Identification and Mitigation Systems called AIIMS for short. They are being used to identify and prevent the impact of infections using computer systems. Don Wright: "I manage the Office of Health Care Quality. Really, the mission of this office is to strengthen the nation's health system and to promote quality care within this country. We're targeting a variety of areas. The reduction, prevention and hopefully elimination of health care associated infections is a prime focus, as is medication error and coordination of care in this country." Chuck: "Is zero the number? Is it rhetoric or reality? Can the reality meet the rhetoric?" Don Wright: "Absolutely, it's reality. And we are focusing on total elimination. When I received my medical training, hospital acquired infections were considered inevitable. But in the decade since that period of time, we now recognize that they are largely preventable. And our goal is complete elimination." Sue Sheridan: "Pat died at 45 years old in 2002 with a 4 year old daughter and a 7 year old son. You know, he had a sense of humor until the very end. And he said Brown, he said, you know, what ever you do you'll be successful but whatever you do, don't give up on patient safety. And he went on to say, go out and kick some butt." Sue Sheridan: "So I started speaking up about what happened to my family and calling for change. And had unique Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 11 of 12 opportunities to testify. At one of the testimonies I met the WHO. Soon after they invited me to join them and lead a program of patients from all over the world just like me who had experienced tragedy in healthcare but wanted to contribute in a really productive, positive way. In effect it was a call to action by patients to the healthcare system to partner with the healthcare system to work with the healthcare system." "This is the exciting part. This is the part that inspires and united people. And for those of us here who have lost family members or children this is the piece that gives us hope. That the WHO says to us patients you're important and your voice, your collective wisdom is important to the WHO. That's a powerful thing for us to hear." Julie Morath: Our future in healthcare to create safer more effective healthcare depends on partnerships with patients and their families. We need patients and families and consumers who are not yet patients or family members to become advocates in the ownership of their own health their own healthcare. And to hold us accountable. Hockey Coach: "When Braxton passed away it was pretty tough for a lot of the kids and it still is tough for some of them. We wanted to run a tournament that sort of exemplified what we felt he was all about and that's sportsmanship. Kids that understand that you're out there to compete and they are going to play against you hard but you're still kids and you're still out there playing a kid's game having fun and that's what it's all about." Steve Rel: "The Braxton story hasn't finished but I think there's a chance for a happy ending. That we and hospitals have a working relationship and no one would have the feel the pain that we've gone through." Dennis Quaid Voice Over: 14 years after Cal's birth the hospital and Sue Sheridan agreed to join forces and put the past behind them to save future patients' lives. This may lead to them becoming a national role model. Sue Sheridan: "The harm that our family experienced was of course unintentional. What we really struggled with was what happened after the harm occurred. And the wall of silence and the isolation that we felt. It was very much like a hit and run. We expect the truth and a sincere attempt to make every effort that that will never happen again to another family." Barton Hill: "When we had the opportunity to connect, for me it was actually relatively easy because I didn't have a lot of history. But I was representing the hospital and I know that it's a difficult time but it's also an awareness that it is time to move forward. Sue, we've come a long way in healthcare. Safety events were considered the cost of doing business. That transition from the cost of doing business is no longer an acceptable option. The challenge that we are facing now is not fully understanding how we get to that point where none will occur. The overriding sense is that it's the right thing to do. And it's an opportunity to see what we can create together." Sue Sheridan: "I am absolutely convinced that we can make a huge difference. So I'm thankful. I'm excited. I look forward to a relationship where we can challenge each other, learn from each other. That we are going to create a model that others are going to wanna copy from Boise, ID." Sue Sheridan: "Pat would say right on. He'd say right on Brown. It is true that when there's profound grief the best medicine for grief is doing something productive. When something bad happens in life we kind of have a choice. We can shrivel up and disappear in life or you can come out fighting like hell. I don't know if it's strength per se but considering what my family has been through I don't see any other route for me. You can come out challenging life. And thank God I'm hopeful. You know, without hope it would be a pretty miserable life." Dennis Quaid Voice Over: Chasing zero is the quest to ensure that accidental death and harm like what happened to my kids are a thing of the past. Zero is within our reach if we have leadership, the right practices in place and we leverage innovative technology. Rosabeth Moss Kanter: Visionaries CEOs that are willing to adopt new principles of management and leadership and deploy them Chasing Zero: Winning the War on Healthcare Harm TMIT Patient Safety Documentary Transcript Page 12 of 12 quickly are going to be successful. They will be the innovators, they're the pioneers. But more than that, they will have the feeling of pride and accomplishment in what they've done for their own organization. I want everybody to remember the essential purpose of why people go into healthcare. It's because they care about people. They care about health status. They care about saving lives. Allan Korn: If the future looks like the past, we'll achieve nothing. In the past 10 or 12 years, we've written a great deal about safety and we've done very little about it. The future has to be roll up your sleeves, let's get going. Those who supply to the hospital and medical industry need to make certain that they not only have safe products and devices, but they're used as safely as possible. Those who use these things must be certain that they're used only to achieve the best possible outcome that they can achieve. And those of us who pay for this care must assure all those families that were paying premiums...that we're using these dollars as wisely as possible to lead to the best possible outcomes in the safest possible environment. David Hunt: We are really bringing the forces, the energy, the resources that we need into this really, really important sphere that now is the time. There is enough knowledge, there is enough energy, we have enough money in the system currently to do what we need to do. What we don't have enough is action. Koh: "We should do everything we can so that people can reach their full potential for health, that's what chasing the zero is all about and that's why it's such an inspirational, aspiration and realistic goal." Don Berwick: I get asked a lot by normal consumers of care what they can do to make their healthcare safer. I generally advise them take someone with you. Make sure that you're not alone in your care system. But I think I'm more and more thinking that the answer is speak up. We have standards. We know, like the National Quality Forum safe practices. We know what standards hospitals should be adopting. As a consumer of care, ask your hospital. Ask them if they're using the kinds of standards that we know can make your care safer. Koh: "So the National Quality Forum Safe Practices are a tremendous opportunity for all leaders now to unleash their full potential, to improve patient safety and healthcare quality and it's time to act now." Dennis Press Club Speech: "I have found the role that I can play and it is to partner with the best experts and drive awareness of what we can do if we act now." Dennis Quaid Voice Over: The Quaid Foundation has merged into TMIT to apply the power of stories to bring consumers and leaders together to act now. Our mission is to save lives, save money and bring value to the communities we serve. Host: Facts, figures and statistics reach the head but nothing happens unless we reach the heart through stories of real people that put the hands to work. Join us in the war on preventable harm.... Zero is the number....now is the time.

Thought Provoking Questions (slides)

Identify moral dilemmas in healthcare informatics that would best be approached with the use of an ethical decision making framework. Discuss the evolving health care ethics traditions within their social and historical context. Differentiate among the theoretical approaches to health care ethics as they relate to the theorists perspectives of individuals and their relationships. Select one of the healthcare ethics theories and support its use in examining ethical issues in healthcare informatics. Select one of the healthcare ethics theories and argue against its use in examining ethical issues in healthcare informatics.

Nursing and Knowledge (slides)

Nurses are knowledge workers -work with information and generating information and knowledge as a product. We are knowledge acquirers -providing convenient and efficient means of capturing and storing knowledge. We are knowledge users - individuals or groups who benefit from valuable, viable knowledge. Nurses are knowledge engineers - designing, developing, implementing and maintaining knowledge. Nurses are knowledge managers -capturing and processing collective expertise and distributing it where it can create the largest benefit. We are knowledge developers or generators - changing and evolving knowledge based on the tasks at hand and information available.

**Cognitive Science**

The application to nursing informatics include problem solving decision support system usability issues user centered interfaces and systems and the development and use of terminologies Studies the mind intelligence and behavior from the information processing perspective. H. Christopher Longuet-Higgins originated the term in his 1973 commentary on the Lighthill report which pertains to the state of artificial intelligence research at that time cognitive science society and cognitive science journal - psychology, philosophy, neuroscience, computer science, linguistics, biology, and physics; covers memory, attention, perception, reasoning, language, mental ability, and computational models of cognitive processes; and explores the nature of the mind, knowledge representation, language, problem solving, decision making, and the special factors influencing the design and use of technology The study of the mind and how information is processed in the mind. The central hypothesis is that thinking can best be understood in terms of representational structures in the mind and computational procedures that operate on the structures. While there is much disagreement about the nature of the representations and computations that constitute thinking the central hypothesis is general enough to encompass the current range of thinking and cognitive science including connectionist theories which model thinking using artificial neural networks

Intro to Information*

The widespread implementation of EHRs has promoted collaboration among public and private sector stakeholders on a wide ranging variety of healthcare information solutions. Some of these initiatives include health level seven HL7 the eGov initiative by consolidated health informatics CHI the National health information infrastructure NHII the national health information network NHIN next generation Internet NGI Internet2 and Ihealth record. There are also health information exchange HIE systems such as connecting for health the ehealth initiative the federal health information exchange FHIE the Indiana health information exchange IHIE the Massachusetts health data consortium MHDC the new England health EDI network NEHEN the state of New Mexico rapid syndrome validation project RSVP the southeast Michigan E-prescribing initiative and the tennessee volunteer ehealth initiative. **Many of these were sparked by the HITECH act of 2011 which set the 2014 deadline for implementing EHRs and provided the impetus for HIE initiatives. One of the main issues of healthcare information technology deals with how healthcare information is managed to make it meaningful - how people obtain manipulate use share and dispose of information

Accessibility

a must, right user (an authorized user who has the right to obtain the data and information that he or she is seeking) must be able to obtain the right information at the right time and in the right format to meet his or her needs. Getting meaningful information to the right user at the right time is vital. Security - challenge - unauthorized users must be blocked, authorized user - open easy access

Nursing Informatics (NI)*

a product of the scientific synthesis of information in nursing encompasses concepts from computer science cognitive science information science and nursing science. A specialty that integrates nursing science computer science and information science to manage and communicate data information knowledge and wisdom in nursing practice. extended to include cognitive science. Clinical information technologies that support and inform nursing practice and nursing administration are an important part of nursing informatics

Casuistry (slides)*

approach to ethical decision-making grew out of the concern for more concrete methods of examining ethical dilemmas. a case based ethical reasoning method that analyzes the facts of a case in a sound, logical and ordered or structured manner. The facts are compared to the decisions arising out of consensus in previous paradigmatic or model cases.

Networks

can be local or organizationally based with computers joined together into a local area network organized on a wider scope like a city or district using a metropolitan area network or encompassing computers at an even greater distance like a whole country or continent using a wide area network configuration

TIGER Initiative*

identified steps towards a ten-year vision and stated a key purpose to create a vision for the future of nursing that bridges the quality chasm with information technology enabling nurses to use informatics and practice and education to provide safer higher quality patient care. The pillars include: -management and leadership: revolutionary leadership that derives empowers and executes the transformation of healthcare. -Education: collaborative learning communities that maximize the possibilities of technology toward knowledge development and dissemination driving rapid deployment and implementation of best practices. -Communication and collaboration: standardized person centered technology enabled processes to facilitate teamwork and relationships across the continuum of care. -Informatics design: evidence-based interoperable intelligence system that support education and practice to foster quality care and safety. -Information technology: smart people centered affordable technologies that are universal useable useful and standards based. -Policy: consistent incentives based initiatives (organizational and governmental) that support advocacy and coalition building achieving and resourcing an ethical culture of safety. -Culture: a respectful open system that leverages technology and informatics across multiple disciplines in an environment where all stakeholders trust each other to work together toward the goal of high quality and safety

Information Science*

the science of information studying the application and usage of information and knowledge in organizations and the interface or interaction between people organizations and ISs. This extensive interdisciplinary science integrates features from cognitive science communication science computer science library science and the social sciences primarily concerned with the input processing output and feedback of data and information through technology integration with a focus on comprehending the perspective of the stakeholders involved and then applying IT as needed. Can also be related to determinism, response to technnologic determinism - the belief that technology develops by its own laws that it realizes it own potential limited only by the material resources available and must therefore be regarded as an autonomous system controlling and ultimately permeating all other subsystems of society

THE ICN CODE OF ETHICS FOR NURSES*

An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is a respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups. guide for action based on social values and needs. applied to the realities of nursing and health care in a changing society.

Summary of Cognitive Science and AI*

Cognitive science is the interdisciplinary field that studies the mind, intelligence, and behavior from an information processing perspective. CI is a field of study that bridges the gap in understanding regarding how information is processed in the mind and in the computer. Computing and informatics theories can be applied to help elucidate the information processing of the brain, and cognitive and neurologic sciences can be applied to build better and more efficient computer processing systems. AI is the field that deals with the conception development, and implementation of informatics tools based on intelligent technologies. This field captures the complex processes of human thought and intelligence. AI uses cognitive science and computer science to replicate and generate human intelligence.

Ethical Decision Making (slides)*

The process of making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. The changing meaning of 'communication' alone will bring with it new concerns by healthcare professionals for protecting patients' rights of confidentiality, privacy, and autonomy.

bioethics*

The study and formulation of healthcare ethics. Takes on relevant ethical problems experienced by healthcare providers in the provision of care to individuals and groups. The fundamental background of bioethics: 1) the nature of needs of humans as living thinking beings 2) the purpose and function of the healthcare system in a human society 3) an increased cultural awareness of human beings essential moral status recording audio/video by a patient requires consent of all parties to any recording or eavesdropping activity An ethical dilemma arises when moral issues raise questions that cannot be answered with a simple clearly defined rule fact or authoritative view.

Nurses and the profession (ICN)*

assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. active in developing a core of research-based professional knowledge that supports evidence-based practice. active in developing and sustaining a core of professional values. participates in creating a positive practice environment and maintaining safe, equitable social and economic working conditions in nursing. practices to sustain and protect the natural environment and is aware of its consequences on health. contributes to an ethical organisational environment and challenges unethical practices and settings. Set standards for nursing practice, research, education and management. Foster workplace support of the conduct, dissemination and utilisation of research related to nursing and health. Promote participation in national nurses' associations so as to create favourable socioeconomic conditions for nurses. Provide teaching/learning opportunities in setting standards for nursing practice, research, education and management. Conduct, disseminate and utilise research to advance the nursing profession. Sensitise learners to the importance of professional nursing associations. Collaborate with others to set standards for nursing education, practice, research and management. Develop position statements, guidelines and standards related to nursing research. Lobby for fair social and economic working conditions in nursing. Develop position statements and guidelines in workplace issues.

Connectionism*

is a component of cognitive science that uses computer modeling through artificial neural networks to explain human intellectual abilities. Neural networks can be thought of as interconnected simple processing devices or simplified models of the brain and nervous system that consists of a considerable number of elements or unit (analogues of neuron) linked together in a pattern of connections (analog of synapses). A neural network that models the entire nervous system would have three types of units 1) input units (analogs of sensory neurons) which receive information to be process 2) hidden units (analogues to all other neurons not sensory or motor) which work in between input and output units and 3) output units (analog of motor neurons) where the outcome or results of the processing are found rooted in how computation occurs in the brain and nervous system or biologic neural networks. on their own, single neurons have minimal computational capacity. When connected with other neurons they have immense computational power. The connectionism system learns by modifying the connections linking the neurons. Artificial neural networks are unique computer programs designed to model or simulate their biologic analogues the neurons of the brain

Microsoft Goals

portability: the OS can be moved from one hardware architecture to another with a few changes needed. Security: OS incorporates hardware protection for virtual memory and software protection mechanisms for OS resources including encryption and digital signature capabilities. Portable operating system interface for UNIX (POSIX) compliance: Applications designed to follow the POSIX standard can be compiled to run on windows without changing the source code. Windows OS have varying levels of compatibility with the applications that ran on earlier versions of Windows OSs multi processor support: the OS is designed for symmetrical multi processing. Extensibility: this capability is provided by using a layered architecture with the protected executive layer for basic system services several servers subsystems that operate in user mode and a modular structure that allows additional environmental subsystems to be added without affecting the executive layer. International support: the windows OS system supports different locales via the national language support application programming interface (API). Compatibility with the MS-DOS and MS windows applications

hard disc

rigid hard disks reside in it, mounted to a spindle that is spun by a motor when in use. Drive heads (most computers have two or more heads) produce a magnetic field through their transducers that magnetizes the disk surface as a voltage is applied to the disk. Acts as a permanent data storage area that holds gigabytes or even terabytes worth of data. The computer writes binary data to the hard drive by magnetizing small areas of its surface. Each drive head is connected to an actuator that moves along the disk to hover over any point on the disk surface as it spins. The part of the hard disk are encased in a sealed unit. The hard drive is managed by a disk controller which is a circuit board that controls the motor and actuator arm assembly. The hard drive produces the voltage waveform that contacts the heads to write and read data and handles communications with the motherboard. It is usually located with in the computers hard outer casing.

Bioethical Decision Making (Husted) (slides)*

centers on the health care professional's implicit agreement with patient/client (Husted and Husted, 1995, p. 19), based on six contemporary bioethical standards: autonomy, freedom, veracity, privacy, beneficence, and fidelity.

morals*

refer to the social convention about right and wrong human conduct that is so widely shared it forms a stable although usually incomplete communal consensus. Moral dilemmas arise with uncertainty as is the case when some evidence a person is confronted with indicates an action is morally right and other evidence indicates that the action is morally wrong. Uncertainty is stressful and in the face of inconclusive evidence on both sides of the dilemma causes the person to question what he or she should do. Uncertainty also arises from unanticipated effects or unforseeable behavioral responses to actions or the lack of action

Nurses and co-workers (ICN)*

sustains a collaborative and respectful relationship with co-workers in nursing and other fields. takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person. takes appropriate action to support and guide co-workers to advance ethical conduct. Create awareness of specific and overlapping functions and the potential for interdisciplinary tensions and create strategies for conflict management. Develop workplace systems that support common professional ethical values and behaviour. Develop mechanisms to safeguard the individual, family or community when their care is endangered by health care personnel. Develop understanding of the roles of other workers. Communicate nursing ethics to other professions. Instil in learners the need to safeguard the individual, family or community when care is endangered by health care personnel. Stimulate co-operation with other related disciplines. Develop awareness of ethical issues of other professions. Provide guidelines, position statements and discussion fora related to safeguarding people when their care is endangered by health care personnel.

Ethics Conclusion (slides)*

As science and technology advances and policy makers and health care providers continue to shape healthcare practices including information management, it is paramount that ethical decisions are made. The healthcare professional cannot allow conflicting loyalties to interfere with judicious, ethical decision making. In an ideal world, healthcare professionals must not be affected by conflicting loyalties; nothing should interfere with judicious, ethical decision making. As the technologically charged waters of health care are navigated, one must hone a solid foundation of ethical decision making and practice it consistently.

Contemporary Bioethical Standards (slides)*

Autonomy - Right of individual to choose for her/himself. Freedom - Ability and right to make choices Veracity - Right to truth/truthfulness. Privacy - related to personal information, and rules that restrict access to this personal information. Beneficience- Refers to actions performed that contribute to the welfare of others. Fidelity - Being faithful to what has been promised.

ETHICAL Model for Decision Making (slides)*

Examine the ethical dilemma Thoroughly comprehend the possible alternatives Hypothesize ethical arguments Investigate, compare, and evaluate the arguments for each alternative Choose the alternative you would recommend Act on your chosen alternative Look at the ethical dilemma and examine the outcomes while reflecting on the ethical decision

Building Blocks of Informatics (slides)*

Nursing Science Information Science Computer Science Cognitive Science

Antiprincipalism (slides)*

Prompted by expansive technological changes and associated ethical dilemmas Opponents of principlism claim principles: are too conceptual, intangible or abstract, disregard or do not take into account a person's psychological factors, personality, life history, sexual orientation, religious, ethnic and cultural background.

Knowledge Viability (slides)

Refers to technology based applications that offer easily accessible, accurate and timely information obtained from a variety of resources and methods and presented in a manner as to provide us with the necessary elements to generate new knowledge. Knowledge must also be viable.

Nursing Code of Ethics (slides)*

The International Council of Nurses Code of Ethics states that "The nurse holds in confidence personal information and uses judgment in sharing this information."

Introduction to Ethical Applications in Informatics (slides)*

The Knowledge Age is changing healthcare in ways that will not be fully recognized and understood for years. The change is paradigmatic and every expert who addresses this change reminds health care professionals of the need to "go with the flow" of rapid change or be left behind.

Use of Wisdom (slides)

Wisdom is the application of knowledge to an appropriate situation. In the practice of nursing science, we expect action and/or actions directed by wisdom. Wisdom uses knowledge and experience to heighten common sense and insight to exercise sound judgment in practical matters. It is developed through knowledge, experience, insight and reflection.

Virtue Ethics (slides)*

approach emphasizes the virtuous character of individuals who make the choices. Suggests that individuals use power to bring about human benefit. One must consider the needs of others and the responsibility to meet those needs. has seen a resurgence in the last thirty years.

Information science

deals with the interchange or flow and scaffolding or structure of information and involves the application of information tools for solutions to patient care and business problems in health care

Information Systems (IS)

iare a collection of interconnected elements that gather process store and distribute data and information while providing a feedback structure to meet an objective. designed for specific purposes within an organization. They are only as functional as the decision-making capabilities problem-solving skills and programming potency built in and the quality of the data and information and put into them Disseminate provide feedback and adjust the data and information based on these dynamic processes

ethical model for ethical decision making*

facilitates the ability to analyze the dilemma and synthesize the information into a plan of action Examine the ethical dilemma (conflicting values exist). Thoroughly comprehend possible alternatives available. Hypothesize ethical arguments. Investigate compare and evaluate the arguments for each alternative. Choose the alternative you would recommend. Act on your chosen alternative. Look at your ethical dilemma and examine the outcomes while reflecting on the ethical decision. Examine the ethical dilemma: use your problem-solving decision making and critical thinking skills. What is the dilemma you're analyzing? Collect as much information about the dilemma as you can making sure to gather the relevant facts that clearly identify the dilemma. You should be able to describe the dilemma you were analyzing in detail. Ascertain exactly what must be decided. Who should be involved in the decision-making process for this specific case? Who are they interested players or stakeholders? Reflect on the viewpoints of these key players and their value systems. What do you think each of the stakeholders would like you to decide as a plan of action for this dilemma? How can you generate the greatest good? Thoroughly comprehend the possible alternatives available: use your problem-solving decision making and critical thinking skills. Create a list of possible alternatives. Be creative when developing your alternatives. Be open minded; there is more than one way to reach a goal. Compel yourself to discern at least three alternatives. Clarify the alternatives available and predict the associated consequences good and bad of each potential alternative or intervention. For each alternative ask the following questions: do any of the principles or rules such as legal professional or organizational automatically nullify this alternative? If this alternative is chosen what do you predict is the best case and worst-case scenarios? Do the best case outcomes outweigh the worst case outcomes? Could you live with the worst case scenario? Will anyone be harmed? If so how will they be harmed? Does the benefit obtained from this alternative overcome the risk of potential harm that it could cost to anyone? Hypothesize ethical arguments: use your problem-solving decision making and critical thinking skills. Determine which of the five approaches apply to this dilemma. Identify the moral principles that can be brought into play to support a conclusion as to what ought to be done ethically in this case or similar cases. Ascertain whether the approaches generate converging or diverging conclusions about what ought to be done Investigate compare and evaluate the arguments for each alternative: use your problem-solving decision making and critical thinking skills. Appraise the relevant facts and assumptions prudently. Is there ambiguous information that must be evaluated? Are there any unjustifiable factual or illogical assumptions or debatable conceptual issues that must be explored? Rate the ethical reasoning and arguments for each alternative in terms of their relative significance. 4 = extreme significance 3 = major significance 2= significant 1 = minor significance. compare and contrast the alternatives available with the values of the key players involved. Reflect on these alternatives: does each alternative consider all of the key players? Does each alternative take into account and reflect an interest in the concerns and welfare of all of the key players? Which alternative will produce the greatest good for the least amount of harm for the greatest number of people? Refer to your professional code of ethical conduct. Did they support your reasoning? Choose the alternative you would recommend: use your problem-solving decision making and critical thinking skills. Make a decision about the best alternative available. Remember the golden rule: does your decision treat others as you would want to be treated? Does your decision take into account and reflect an interest in the concerns and welfare of all of the key players? Does your decision maximize the benefit and minimize the risk for everyone involved? Become your own critic - challenge your decision as you think others might. Use the ethical arguments you predicted they would use and defend your decision. Would you be secure enough in your ethical decision making process to see it aired on national television or sent out globally over the Internet? Are you secure enough with this this ethical decision that you could have allowed your loved ones to observe your decision making process your decision and it's outcomes? Act on your chosen alternative: use your problem-solving decision making and critical thinking skills. Formulate an implementation plan delineating the execution of the decision. This plan should be designed to maximize the benefits and minimize the risks. This plan must take into account all of the resources necessary for implementation and training personnel and money. Implement the plan. Look at the ethical dilemma and examine the outcomes while reflecting on your ethical decision: use your problem-solving decision making and critical thinking skills. monitor the implementation plan and it's outcomes. It is extremely important to reflect on specific case decisions and evaluate their outcomes to develop your ethical decision making ability. If new information becomes available the plan must be re-evaulated. Monitor and revise the plan as necessary.

Data mining*

nurse administrators and nurse researchers can glean information about best practices and determine which improvements are necessary to deliver the best and most effective nursing care based on a collection of data about patients in a database

Care Ethics (slides)*

responsiveness to the needs of others dictates providing care, preventing harm and maintaining relationships. based on relationships and a caring attitude toward others. care ethicists are less guided by rule focus is on the needs of others and one's responsibility to meet those needs.

Utility

the ability to provide the right information at the right time to the right person for the right purpose. Transparency allows users to apply their intellect to accomplish their tasks while the tools housing information disappear into the background.

Quality of Information (slides)

Necessary for it to be valuable and meaningful. Characteristics of valuable, quality information accessibility, security, timeliness, accuracy, relevancy, completeness, flexibility, reliability, objectivity, utility, transparency, verifiability, and reproducibility

Nurses and practice (ICN)*

carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. maintains a standard of personal health such that the ability to provide care is not compromised. uses judgement regarding individual competence when accepting and delegating responsibility. maintains standards of personal conduct which reflect well on the profession and enhance its image and public confidence. ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people. strives to foster and maintain a practice culture promoting ethical behaviour and open dialogue. Establish standards of care and a work setting that promotes quality care. Establish systems for professional appraisal, continuing education and systematic renewal of licensure to practice. Monitor and promote the personal health of nursing staff in relation to their competence for practice. Provide teaching/ learning opportunities that foster life long learning and competence for practice. Conduct and disseminate research that shows links between continual learning and competence to practice. Promote the importance of personal health and illustrate its relation toother values. Provide access to continuing education, through journals, conferences, distance education, etc. Lobby to ensure continuing education opportunities and quality care standards. Promote healthy lifestyles for nursing professionals. Lobby for healthy workplaces and services for nurses.

nursing informatics*

combo of nursing science, computer science, and information science used to describe the processes nurses use to manage data, information, and knowledge in nursing practice development of decision support software embedded into the electronic health record - models the human and natural decision-making processes of professionals in an artificial program. - help decision makers to consider the consequences of different courses of action before implementing the action, provide stores of info that the user may not be aware and can use to choose the best course of action and ultimately a better decision in unfamiliar circumstances.

Ethics*

is a process of systematically examining varying viewpoints related to moral questions of right and wrong. a generic term for various ways of understanding and examining the moral life. Normative presenting standards of right or good action descriptive reporting what people believe in how they act or explorative analyzing the concepts and methods of ethics Examines the way men and women can exercise their power in order to bring about human benefit; the ways in which one can act in order to bring about the conditions of happiness Well based standards of right and wrong that prescribe what humans ought to do usually in terms of rights obligations benefits to society fairness or specific virtues refers to the study and development of one's ethical standards dialectical, goal-oriented approach to answering questions that have the potential for multiple acceptable answers

Nursing science*

is the ethical application of knowledge acquired through education research and practice to provide services and interventions to patients to maintain enhance or restore their health and to acquire process generate and disseminate nursing knowledge to advance the nursing. building block of nursing informatics The ANA 2016 - nursing is the protection promotion and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals families groups communities and populations

random access memory (RAM)

volatile memory, temporary storage system that allows the processor to access program codes and data while working on a task, contests are lost once the system is rebooted, shut off, or loses power The memory is actually situated on small chip boards which sport rows of pins along the bottom edge and are plugged into the motherboard of the computer. These memory chips contain complex arrays of tiny memory circuits that can be either set by the processor during write operations (puts them into storage) or read during data retrieval. The circuit store the data in binary form as either or low on voltage stage expressed as a zero or a high off voltage state expressed as a one. All the work being done on a computer resides in ram until it is saved onto the hard drive or other storage drive. Computers generally come with 2 GB of RAM or more and some offer more RAM via graphics cards or other expansion cards. A certain portion of the ram called the main memory serves the hard disk and facilitates interactions between the ard disk and central processor. Main memory is provided by a dynamic random access memory (dram) and is attached to the processor using specific addresses and data buses. Synchronous dynamic random access memory (sdram) also known as static dynamic ram protects its data bits. The newer chip is double data rate synchronous dynamic random access memory (DDR sdram) that allows for greater bandwith and twice the transfers for the computers internal clocks unit of time

Antiprincipalism*

Antiprincipalism - a movement emerged in the 21st-century with the expansive technological changes and the tremendous rise in ethical dilemmas accompanying these changes. Opponents of principle included those who claim that it's principles do not represent a theoretical approach as well as those who claim that it's principles are too far removed from the concrete particularities of every day human existence; are too conceptual intangible or abstract; or disregard or do not take into account a persons psychological factors personality life history sexual orientation or religious ethnic and cultural background. The casuist approach to ethical decision making grew out of the call for more concrete methods of examining ethical dilemmas. Casuistry is a case based ethical reasoning method that analyzes the facts of the case in a sound logical and ordered or structured manner. The facts are compared to decisions arising out of consensus in previous paradigmatic or model cases. Jones prefers particular and concrete paradigms and analogies over the universal and abstract theories of principals The Husted bioethical decision making model centers on the healthcare professionals implicit agreement with the patient or client. It is based on six contemporary bioethical standards autonomy freedom veracity privacy beneficiaries and fidelity

Examples of Information Systems

Clinical information system CIS - comprehensive and integrative system that manages the administrative financial and clinical aspects of a clinical facility CIS should help to link financial ann clinical outcomes example is EHR. Decision support system DSS - organizes and analyzes information to help decision makers formulate decisions when they're unsure of their decisions possible outcomes. After gathering relevant and useful information develops what if models to analyze the options or choices and alternatives. Executive support system - collects organizes analyzes and summarizes vital information to help executives or senior management with strategic decision making. Provides a quick view of all strategic business activities. Geographic information system GIS - collects manipulates analyzes and generates information related to geographic locations or the surface of the earth. provides output in the form of virtual models maps or lists. Management information systems MIS - provide summaries of internal sources of information such as information from the transaction processing system and develops a series of routine reports for decision-making. Office systems - facilitates communication and enhances the productivity of users needing to process data and information. Transaction processing system TPS - processes and records routine business transactions such as billing systems that create and send invoices to customers and payroll systems that generate employees pay stubs and wage checks and calculate tax payments. Hospital information system HIS - manages the administrative financial and clinical aspects of a hospital enterprise. It should help to link financial and clinical outcomes

Information System (slides)

Combinations of hardware, software and telecommunications networks that people build and use to collect, create, and distribute useful data, typically in organizational settings Can be manually based, but for the purposes of this text, the term refers to computer-based information systems (CBISs) Designed for specific purposes within organizations Acquires data or inputs; processes data that consists of the retrieval, analysis, and/or synthesis of data; disseminates or outputs in the form of reports, documents, summaries, alerts, prompts, and/or outcomes; and provides for responses or feedback Capability to disseminate, provide feedback, and adjust the data and information based on these dynamic processes are what sets them apart should be a user-friendly entity that provides the right information at the right time and in the right place. Organizations are recognizing that their most precious asset is their information, represented in their employees, experience, competence or know-how, and innovative or novel approaches, all of which are dependent on a robust information network that encompasses the information technology infrastructure.

Computers

Most computers are based on scientist John von Neumann's model of a processor - memory - input - output architecture. the logic unit and control unit are parts of the processor the memory is the storage region and the input and output segments are provided by the various computer devices such as keyboard mouse monitor and printer. Parallel computing model - multiple processors are set up to work together The processer contain specific mechanical units including registers arithmetic logic units a floating point unit control circuitry and cache memory. these inner components form the computer central processor. registers consist of data storing circuits whose contents are processed by the adjacent arithmetic and logic units or the floating point unit. Cache memory is extremely quick memory that holds whatever data and code are being used at any one time. The processor uses the cache to store in-process data so that it can be quickly retrieved as needed. speed and power of processor used to be measured in megahertz - MHz. Today more common to see gigahertz Ghz. 1 ghz = 1000 mhz so much faster. the more cycles a processor can complete per second the faster computer programs can run. intel new technologist - favor better energy consumption over faster election times - end to "moore's law" which predicted the doubling of density in integrated circuits and speed every two years multicore microprocessors - chips that combine two or more processors. multiple microprocessors have become a standard in servers using microprocessors and multiprocessors have replaced most mainframes supercomputers - collections of microprocessors mobile uses mainframes The essential structures of the motherboard include major chipset Super Input/Output chip basic input/output system read only memory, bus communication pathways and a variety of sockets that allow components to plug into the board. The chipset often a pair of chips determines the computer CPU type of memory. It also houses the North bridge and South bridge controllers that allow the buses to transfer data from one to another power supply converts the 120-volt AC main power (power cable plugged into wall socket) into low-voltage DC power. computers depend on DC power to function. The more devices and programs used on comp, the more power supply needed. Power supplies normally range from 160-700 watts, avg 300-400 watts.

AACN Education - Informatics*

The essentials of baccalaureate education for professional nursing practice AACN includes the following: 1) demonstrate skills in using patient care technologies information systems and communication devices that support safe nursing practice. 2) use telecommunications technology to assist in effective communication any variety of healthcare settings. 3) Apply safe guards and decision making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers. 4) Understand the use of CIS to document interventions related to achieving nurse sensitive outcomes. 5) Use standardized terminology in a care environment that reflects nursings unique contribution to patient outcomes. 6) Evaluate data from all relevant sources including technology to inform the delivery of care. 7) Recognize the role of information technology in improving patient care outcomes and creating a safe care environment. 8) Uphold ethical standards related to data security regulatory requirements confidentiality and clients right to privacy. 9) Apply patient care technologies as appropriate to address the needs of a diverse patient population. 10) Advocate for the use of new patient care technologies for safe quality care. 11) Recognize that redesign of workflow and care processes should precede implementation of care technology to facilitate nursing practice. 12) Participate in the evaluation of information systems and practice settings for policy and procedure development The report suggests the following sample content for achieving the student outcomes: -use of patient care technologies monitors pimps computer assisted devices -use of technology and information systems for clinical decision-making -computer skills that may include basic software spreadsheet and healthcare databases information management for patient safety -regulatory requirement through electronic data monitoring systems -ethical and legal issues related to the use of information technology including copyright -privacy and confidentiality issues -retrieval information systems including access evaluation of data and application of relevant data to meet patient care -online literature searches -technological resources for evidence-based practice -web based learning and online literature searches for self and patient use -technology and information systems safeguards like patient monitoring equipment patient identification systems drug alerts and IV systems and barcoding -interstate practice regulations licensure Telehealth -technology for virtual care delivery and monitoring -principles related to nursing workload measurement and resources and information systems -information literacy -electronic health record and physician order entry -decision support tools -role of the nurse informaticist in the context of health informatics and information systems The informatics and healthcare technologies essential of masters education in nursing includes the following elements: (AACN) informatics and healthcare technologies encompass five broad areas: -use of patient care and other technologies to deliver and enhance care -communication technologies to integrate and coordinate care -data management to analyze and improve outcomes of care -Health information management for evidence-based care and health education -facilitation and use of electronic health records to improve patient care

Nursing in the Future (slides)*

The future of nursing science and nursing informatics is intimately associated with the nursing education and nursing research arenas. Skiba (2007) suggests that we need techno-saavy and well-informed faculty who can demonstrate the appropriate use of technologies to enhance the delivery of nursing care. Informatics and the use of technology in the practice of nursing are equally important in the nursing research arena. Participants in the development of The National Nursing Research Agenda (NNRA) identified these two technology related priorities (among other research priorities) for nursing research: Nursing Informatics: Enhancing Patient Care Technology Dependency across the Life-span Goosen (2002) believes that the focus on nursing informatics research should be on the structuring and processing of patient information and how these inform nursing decision making in clinical practice. It is clear that the increasing use of technology to enhance nursing practice, nursing education, and nursing research will open new avenues for acquiring, processing, generating, and disseminating knowledge.

Nursing Science and Informatics (slides)*

What is nursing informatics? One of the most frequently quoted and widely accepted definitions of nursing informatics is that it is a combination of nursing science, information science and computer science (we add Cognitive Science as well) Nursing Science as a building block of nursing informatics

Applying Ethics to Informatics (slides)*

With the knowledge age has come global closeness or the ability to reach around the globe instantaneously through technology. Language barriers are being broken through technological translators to enhance our interaction and exchange of data and information. Informatics practitioners are bridging continents and international panels, committees and organizations are beginning to establish standards and rules for the implementation of informatics. The ethical approaches can be used to help healthcare professionals make ethical decisions in all areas of practice. Typically situations are analyzed using our past experience and in collaboration with others. The use of expert systems, decision support tools, evidence-based practice and artificial intelligence in the care of our patients provides challenges as to who should use these tools, how they are implemented and how they are tempered with clinical judgment. Facing ethical dilemmas on a daily basis and struggling with unique client situations cause many clinicians to question their own actions as well as the actions of their colleagues and patients. The goal of any ethical system should be that a rational, justifiable decision was reached. The information concerning an ethical dilemma must remain in the context of the dilemma in order to be useful. Bio-informatics could gather, manipulate, classify, analyze, synthesize, retrieve and maintain databases related to ethical cases, the effective reasoning applied to various ethical dilemmas and the resulting ethical decisions. In order to make ethical decisions about informatics technologies and patients' intimate healthcare data and information, we must be informatics competent. Just as we use processes and models to diagnose and treat our patients in practice, we can also apply a model in the analysis and synthesis of ethical dilemmas or cases.

Computer science

deals with understanding the development design structure and relationship of computer hardware and software

Monitors

either are based on cathode ray tube the conventional monitor with a large section behind the screen or are thinner flatscreen liquid crystal display devices. Monitors very in the refresh rate usually measured in megahertz and dot pitch. The faster the refresh rate the cleaner and clearer the image on the screen because the monitor refreshes the screen content more frequently. The larger the dot pitch factor the smaller the dots that make up the screen image which provides a more detailed display on the monitor and also facilitates clarity and ease of viewing smartphone displays can be a form of AMOLED (Active Matrix Organic Light Emitting Diode) or IPD LCD (In-Plane Switching Liquid Crystal Display). In the AMOLED type, the individual pixels are lit separately (active matrix); the next-generation super AMOLED type includes touch sensors. The IPD LCD-type uses polarized light passing through a color filter and all of the pixels are back-lit. The liquid crystals control the brightness and which pixels are on or off. With the active matrix, you have crisp, vivid colors and darker blacks.

Virtue Ethics*

emphasizes the virtuous character of individuals who make the choices. A virtue is any characteristic or disposition desired in others or oneself. Refers to what one expects of oneself and others - excellence. Virtue ethicists emphasize the ideal situation and attempt to identify and define ideals. Dates back to Plato and Socrates. If virtue is knowledge than it can be taught. The cause of any moral weakness is not a matter of character flaws but rather a matter of ignorance. A person acts immorally because the individual does not know what is really good for him or her. Plato emphasizes that to lead a moral life and not to succumb to immediate pleasures and gratification one must have a moral vision. he identified four cardinal virtues wisdom courage self-control and justice Aristotle's Nichmachean principles also contribute to virtue ethics. Virtues are connected to will and motive because the intention is what determines if one is or is not acting virtuously. Ethical consideration according to his eudaemonistic principles address the question what is it to be an excellent person? This ultimately means acting in a temperate manner according to a rational mean between extreme possibilities Pellegrino and Thomasma maintain that virtue theory should be related to other theories within a comprehensive philosophy of the health professions. They argue that moral events are composed of four elements the agent the actor the circumstances and the consequences and state that a variety of theories must be into related to account for different facets of moral judgement

Read only memory ROM

essential permanent or semipermanent non-volatile memory that stores save data and is critical in the working of the computers OS and other activities. Stored primarily in the motherboard may also be available through a graphics card other expansion cards and peripherals. Rewritable ROM chips - include other forms of ROM such as programmable read only memory (prom) erasable ROM electronically erasable programmable read only memory (EE prom) and flash memory a variation of electronically erasable programmable ROM have become available The basic input/output system (bios) is a specific type of ROM used by the computer when it first boots up to establish basic communication between the processor motherboard and other components. Often called boot firmware it controls the computer from the time the machine is switched on until the primary OS takes over. The firmware initializes the hardware and boots the primary OS Virtual memory is a special type of memory that is stored on the hard disk to provide temporary data storage so data can be swapped in and out of the ram as needed. This capability is particularly handy when working with large data intensive programs the integrated driver electronics (IDE) controller component is the primary interface for the hard drive cd ROM DVD drive and floppy drive Flash Drive - uses electronically erasable programmable ROM Parallel Port - connects to a printer Serial Port - connects to external modem byte - chunk of memory that consists of 8 bits

cognitive informatics*

field of study that bridges the gap in understanding regarding how information is processed in the mind and in the computer. desire to develop an understanding of natural intelligence and human problem solving. the disciplines neuroscience, linguistics, AI, and psychologist constitute this field the multidisciplinary study of cognition and information sciences, which investigates human information processing mechanisms and processes and their engineering applications in computing systematically exploring the mechanisms of the brain and mind and exploring how information is acquired, represented, remembered, retrieved, generated, and communicated. this can be applied and modeled in AI situations -> more efficiency computing applications attempts to solve problems in two connected area in a bidirectional and multidisciplinary approach - uses informatics and computing techniques to investigate cognitive science problems such as memory learning and reasoning, uses cognitive theories to investigate the problem in informatics, computing and software engineering can be used to build IT systems that better meet the needs of users. The National Center for Cognitive Informatics and Decision Making in Healthcare (NCCD) - established to respond to the urgent and long-term cognitive challenges in health IT adoption and meaningful use. - provide strategic leadership in patient-centered cognitive support research and applications in health care Human Mental Workload (MWL) as a key component in effective systems design cognitive informatics - study of brain and human information processing informs system design: models cognitive processes, consider human mental workload usable systems - easy and intuitive, support nursing practice and decision making

cloud computing

link systems together and reduce costs The public cloud is owned and operated by companies offering public access to computing resources. It is believed to be more affordable and economically sound because the user does not need to purchase the hardware software or supporting infrastructure as they are managed and owned by the cloud provider. The private cloud is operated for a single organization with the infrastructure being managed and or hosted internally or outsourced to a third-party; it provides added control and avoids multi tenancy. cloud computing advantages: agile deployment, increased productivity, pay as you go as needed, sustainable, reliable, situational and context-driven, enhanced collaboration, scalable: dynamic rep up or dynamic ramp down, resources: shared and distributed, flexible, less capital expenditures, user-distinct encounters and experiences, market adaptability services based in the cloud that are mainly business related - software as a service SaaS, platform as a service PaaS and infrastructure as a service IaaS. SaaS, such as salesforce.com refers to a cloud based application with the following benefits: quickly start using innovative or specific business apps that are scalable to your needs, any connected computer can access the apps and data, and data is not lost if your hard drive crashes because the data is stored in the cloud. PaaS provide everything you need to support the clouds application building and delivery enabling users to develop and launch custom web applications rapidly to the cloud. IaaS such as Amazon Microsoft google and Rackspace provide a rentable backbone to companies enabling the scalable on-demand infrastructure they need to support their dynamic workloads; the user pays only for what they use and he or she does not have to invest in hardware such as networks storage and data center space

artificial intelligence (AI)*

model human thinking using artificial networks provided by computers provide the scaffolding for the analysis and modeling of complicated, multifaceted human performance and has a tremendous effect on the issues impacting informatics The conception development and implementation of informatics tools based on intelligent technologies. Captures the complex processes of human thought and intelligence uses the power of computers to augment human thinking use a computers artificial intelligence to understand how humans think The scientific understanding of the mechanisms underlying thought and intelligent behavior and their environment and machines. The science and engineering of making intelligent machines especially intelligent computer programs. Using computers to understand human intelligence but it does not have to confine itself to methods that are biologically observable. The ability to perform a task that is normally performed by natural intelligence particularly human natural intelligence. Can perform many tasks that used to require human intelligence. The computational part of the ability to achieve goals in the world. uses cognitive science and computer science to replicate and generate human intelligence. monitor huge quantities of data to automatically detect threats to patient safety, patterns of suboptimal care as well as outbreaks of hospital acquired illness

Nurses and people (ICN)*

primary professional responsibility is to people requiring nursing care. promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent for care and related treatment. holds in confidence personal information and uses judgement in sharing this information. shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. advocates for equity and social justice in resource allocation, access to health care and other social and economic services. demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity. Provide care that respects human rights and is sensitive to the values, customs and beliefs of people. Provide continuing education in ethical issues. Provide sufficient information to permit informed consent to nursing and/or medical care, and the right to choose or refuse treatment. Use recording and information management systems that ensure confidentiality. Develop and monitor environmental safety in the workplace. In curriculum include references to human rights, equity, justice, solidarity as the basis for access to care. Provide teaching and learning opportunities for ethical issues and decision making. Provide teaching/ learning opportunities related to informed consent, privacy and confidentiality, beneficence and maleficence. Introduce into curriculum concepts of professional values. Sensitise students to the importance of social action in current concerns. Develop position statements and guidelines that support human rights and ethical standards. Lobby for involvement of nurses in ethics committees. Provide guidelines, position statements, relevant documentation and continuing education related to informed consent to nursing and medical care. Incorporate issues of confidentiality and privacy into a national code of ethics for nurses. Advocate for safe and healthy environment.

consensus-based approach to bioethics*

proposed by Martin claims that American bioethics harbors a variety of ethical methods that emphasize different ethical factors including principles circumstances character interpersonal needs and personal meaning. Each method reflects an important aspect of ethical experience adds to the others and enriches the ethical imagination. Thus working with these methods provide the challenge and the opportunity necessary for the perceptive and shrewd bioethicist to transform them into something new with value through the process of building ethical consensus. Diverse ethical insights can be integrated to support a particular bioethical decision and that decision can be understood as a new ethical whole The need for confidentiality was perhaps first articulated by Hippocrates; it is simply the ways in which confidentiality can be violated

ethical decision making*

refers to the process of making informed choices about ethical dilemmas based on a set of standards differentiating right from wrong. This type of decision making reflects an understanding of the principles and standards of ethical decision making as well as the philosophical approaches to ethical decision making and it requires a systematic framework for addressing the complex and often controversial moral questions Organizations and individuals that provide health information on the Internet have obligations to be trustworthy provide high-quality content protect users privacy and adhere to standards of best practice for online commerce and online professional services in healthcare Internet healthcare coalition develop the E health code of ethics includes eight standards for the ethical development of health related Internet sites candor and honesty quality informed consent privacy professionalism responsible partnering and accountability Hippocratic tradition - homogenous societies, beliefs were similar, societal members share common values. the emphasis was on duty, virtue and gentlemanly conduct

Principalism*

societies became more heterogenous and members began experiencing a diversity of incompatible believes and values ; it emerged as a foundation for ethical decision making. Principles were expansive enough to be shared by all rational individuals regardless of their background and individual beliefs. 1900s - Beauchamp and childress. last quarter of 20th century. Principles are considered broad guidelines that provide guidance or direction but leave substantial room case-specific judgment. From principles one can develop more detailed rules and policies. Beauchamp and childress proposed four guiding principles: respect autonomy nonmaleficence beneficence and justice. Autonomy refers to the individuals freedom from controlling interferences by others and from personal limitations that prevent meaningful choices such as adequate understanding. Two conditions are essential for autonomy: liberty meaning the independence from controlling influences and the individuals capacity for intentional action. Nonmaleficence asserts an obligation not to inflict harm intentionally and forms the framework for the standard of due care to be met by any professional. Obligations of nonmaleficence are obligations of not inflicting harm and not imposing risk of harm. Negligence a departure from the standard of due care towards others include intentionally imposing risks that are unreasonable and unintentionally but carelessly imposing risks. Beneficence refers to actions performed that contribute to the welfare of others. Two principles underlying beneficence: positive beneficence requires the provision of benefits and utility requires that benefits and drawbacks be balanced. One must avoid negative beneficence which occurs when constraints are placed on activities that even though they might not be unjust could in some situations cause detriment or harm to others Justice refers to fair equitable and appropriate treatment in light of what is due or owed to a person. Distributive justice refers to fair equitable and appropriate distribution in a society determined by justified norms that structure the terms of social cooperation Three types of rules for guiding actions: substantial authority and procedural rules are more restrictive in scope then principles and are more specific in content. Substantive rules are rules of truth telling confidentiality and privacy and fidelity and those pertaining to the allocation and rationing of healthcare omitting treatment physician assisted suicide and informed consent. authority rules indicate who may and should perform actions. Procedural rules established procedures to be followed

QSEN institute project**

the QSEN institute project seeks to prepare future nurses who will have the knowledge skills and attitudes (KSA) necessary to continuously improve the quality and safety of the healthcare systems within which they work Pre-licensure informatics KSA: k: explain why information and technology skills are essential for safe patient care s: seek education about how information is managed in care settings before providing care apply technology and information management tools to support safe processes of care a: appreciate the necessity for all health professionals to seek lifelong continuous learning of information technology skills K: identify essential information that must be available in a common database to support patient care. Contrast benefits and limitations of different communication technologies and their impact on safety and quality S: navigate the electronic health record. Document and plan patient care in an electronic health record. Employ communication technologies to coordinate care for patients. A: value technologies that support clinical decision-making error prevention and care coordination. Protect the confidentiality of protected health information in an electronic health record. K describe examples of how technology and information management are related to the quality and safety of patient care. Recognize the time effort and skill required for computer databases and other technologies to become reliable and effective tools for patient care. S: respond appropriately to clinical decision-making supports and alerts. Use information management tools to monitor outcomes of care processes. Use high-quality electronic sources of healthcare information. A: value nurses involvement in design selection implementation and evaluation of information technologies to support patient care definition: use information and technology to communicate manage knowledge mitigate error and support decision making Graduate level informatics KSA's include the following A: contrast the benefits and limitations of common information technology strategies used in the delivery of patient care. Evaluate the strengths and weaknesses of information systems used in patient care. S: participate in the selection design implementation and evaluation of information systems. Communicate the integral role of information technology in nurses work. Model behaviors that support implementation and appropriate use of electronic health records. Assist team members to adopt information technology by piloting and evaluating proposed technologies. A: value the use of information and communication technologies in patient care. K: formulate essential information that must be available in a common database to support patient care in the practice specialty. Evaluate benefits and limitations of different communication technologies and their impact on safety and quality. S: promote access to patient care information for all professionals who provide care to patients. Serve as a resource for how to document nursing care at basic and advanced levels. Develop safeguards for protected health information. Champion communication technologies that support clinical decision-making error prevention care coordination and protection of patient privacy. A: appreciate the need for consensus and collaboration and developing systems to manage information for patient care. Value the confidentiality and security of all patient records. K: describe and critique taxonomic and terminology systems used in national efforts to enhance interoperability of information systems and knowledge management systems. S: access and evaluate high-quality electronic sources of healthcare information. Participate in the design of clinical decision-making supports and alerts. Search retrieve and manage data to make decisions using information and knowledge management systems. Anticipate unintended consequences of new technology. A: value the importance of standardized terminologieis in conducting searches for a patient information. Appreciate the contribution of technological alert systems. Appreciate the time effort and skill required for computers databases and other technologies become reliable and effective tools for patient care. Definition: use information and technology to communicate, manage knowledge, mitigate error and support decision making

APPLYING THE ELEMENTS of the ICN Code of Ethics for Nurses*

● Study the standards under each element of the Code. ● Reflect on what each standard means to you. Think about how you can apply ethics in your nursing domain: practice, education, research or management. ● Discuss the Code with co-workers and others. ● Use a specific example from experience to identify ethical dilemmas and standards of conduct as outlined in the Code. Identify how you would resolve the dilemmas. ● Work in groups to clarify ethical decision making and reach a consensus on standards of ethical conduct. ● Collaborate with your National Nurses Association, co-workers, and others in the continuous application of ethical standards in nursing practice, education, management and research.