After she started looking at adverse events as system failures, rather than solely personal failures, she engaged the staff to redesign systems. She introduced HF concepts and provided an infrastructure to make it safe to report and discuss problems. The project included a new medication error reporting system and the creation of departmental patient safety teams. A palpable culture change developed when front-line staff and managers became empowered to find solutions working side-by-side with the quality and risk management departments.
The result? A dramatic increase in medication errors and near-miss reports: from eight faulty problems per quarter in 2000 to 200 reports per quarter by 2001.
To sum up the essence of Dr. Nagamine’s project, she invokes her favorite quotation from systems expert James Reason: “We can’t change the human condition, but we can change the conditions under which humans work.”1,5
Bar coding workarounds: Hospitalist Tosha Wetterneck, MD, and her colleagues at the University of Wisconsin School of Medicine and Dentistry focused their HF-trained eyes on medication errors.5 The team applied HF concepts as part of a study of bar-coded medication administration systems (BCMAs). Ideally, BCMAs help confirm the five rights of medication administration: the right patient, drug, dose, route, and time. The study authors identified the hospitalist staff had developed 46 workarounds in place of proper use of the BCMA. With each workaround, the researchers identified six potential errors. Furthermore, nurses were overriding the BCMA alerts for 4.2% of patients charted, and for 10.3% of total medication.
By creating an exhaustive template, the study authors broke down the use of BCMA workarounds to the finest detail of task component. They learned many workarounds were engendered by difficulties with the technology and by interactions between BCMA technologies and environmental, technical, process, workload, training, and policy concerns. Data shows BCMAs still have an important role in preventing error; during one year, almost 24,000 BCMA alerts led users to change their action, instead of overriding an alert. “These causes (and related workarounds) are neither rare nor secret,” the authors write. “They are hiding in plain sight.”1,5
Dr. Wetterneck is part of the Systems Engineering Initiative for Patient Safety (SEIPS), an interdisciplinary research group located within the Center for Quality and Productivity Improvement in the College of Engineering at the University of Wisconsin-Madison.6,7 SEIPS uses HF principles to study the safety and quality of healthcare systems.
Congestive heart failure order sets: Researchers in another study incorporated HF science in their review of clinical practice guideline use and application for congestive heart failure (CHF). Reingold and Kulstad studied the impact of HF design elements on order set utilization and recommendations compliance.8
Using retrospective medical record review of adult patients admitted from the emergency department with CHF, the study measured acuity and clinical practice guideline (CPG) parameters before and after introducing new orders. In 87 adult patients before and 84 patients after beginning the new order set, attention to HF design elements significantly improved utilization of the orders and CPG compliance.
Infusion device programming: In another instance, a multidisciplinary research team applied HF design principles to common nursing procedures: programming an insulin infusion and programming a heparin infusion.9,10 An HF usability checklist was developed, and it revealed systematic error-provoking conditions in both tasks.
The good news is the pitfalls were remedied easily.
Not only did researchers subsequently commit to modify training procedures and redesign preprinted orders, they took the bigger step of providing feedback to the manufacturer and committing to incorporate usability testing in future procurement of medical devices. TH
Andrea M. Sattinger is a medical writer based in North Carolina and a frequent contributor to The Hospitalist.