Medbook Application and Medtray


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Medical Design project of Design & Engineering course. Autumn semester 2013/2014

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Medbook Application and Medtray

  1. 1. MedBook application & MedTray Medicine distribution project report 2013/2014
  2. 2. Contents 1.BACKGROUND 7 1.1 Introduction 7 1.2 Project aim and objectives 7 1.3 General information about hospital 8 1.4 Patient Safety as a subliminal issue in health care policy 1.5 To err is human 10 2. CURRENT SYSTEM 11 3. CONCEPT 14 3.1 Need 14 3.2 General concept 14 3.3 Mapping of information flow. 15 3.4 Different existing concepts 18 4.DESIGN 21 4.1 Interface of the App 21 4.2 Appearance 27 4.3 Making a prototype for a MedTray 4.4 Product value 34 5. SUMMARY 36 6. REFERENCES 36 33 9
  3. 3. Team Gina Metssalu TTU BSc Mechanical Engineering Estonia Karl Annus Tartu Art College Furniture Design Estonia Jibing Wu China,Beijing Afshin Hasani TTU BSc Mechanical Engineering Iran
  4. 4. 1.BACKGROUND 1.1 Introduction This report details a medical design project in cooperation with North Estonia Medical Center (PõhjaEesti Regionaalhaigla) and Design and Engineering Masters program students at Tallinn University of Technology. 1.2 Project aim and objectives Our project aim was to find design solutions on the field’s of patients’ safety and/or dignity in hospital. From the field research that we carried out in the hospital, we found several issues that could be improved both the patients and caretakers point of view. Our group concentrated on medication distribution system in hospital departments. We found out that current system with several handwritten lists and papers is not unequivocal for everyone and creates diverse base for human errors. We think that mistakes can best be prevented by designing the system at all levels to make it safer - to make it harder for people to do something wrong and easier for them to do it right. By virtue of their direct patient-care activities and administration of medications to patients, nurses— perhaps more than any other health-care providers—are in an excellent position to prevent, detect and report medication errors. Nurses play an important role in risk reduction. Thats why the main objectives of the proposed project are targeted to designing the nurses working system, although the benefits will rise up at all levels of system. After analyzing current system and background research we worked out one possible solution what we are introducing on the following pages of the report. 7
  5. 5. 1.3 General information about hospital 1.4 Patient Safety as a subliminal issue in health care policy The North Estonia Medical Centre is Estonia’s foremost hospital. Their mission is to provide top-level patient-friendly health care and to promote the development of medicine in Estonia. The hospital is a higher level medical institution. The main topic of this project is patient safety as an important health care policy aspect. Patient safety has been internationally well identified as an important health care problem and research issue, but Estonia lacks a common understanding not only on patient safety, but also on health care main target. There are also no national policy nor strategy document contains a patient safety perspective. At the same time road safety, for example, is topic what is several times more dealt with in Estonia. The patient safety topic is often compared with aviation what is regulated with high level of safety requirements. Institute of Medicine report „To Err is Human“ (1) says that according to estimates from two major studies at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented. As an example we can bring the reference to U.S aviation safety report according to which the average traveler has to fly 438 years in a row to get a partial in a plane crash. Medical operations are managed through seven clinical divisions – Anesthesiology Clinic, Diagnostics Division, Surgery Clinic, Psychiatry Clinic, Oncology and Hematology Clinic, Internal Medicine Clinic and Follow-up Care Clinic. Hospital provides services in almost all medical specialties (excl. ophthalmology, paediatrics and obstetrics). Hospital’s main buildings are situated in Tallinn (different locations) and Kose. The hospital is an employer for 3626 people, including 590 doctors, 1352 nursing staff and 862 caregivers. There are over 100 resident doctors in the hospital at any given time. Medical staff are supported by approx. 714 workers. Hospital is legal person governed by private law and its legal form is foundation. Hospital has been founded by the Republic of Estonia. Hospital’s official name is Sihtasutus Põhja-Eesti Regionaalhaigla. Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (in­ luding the expense of additional care necessitated by the c errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals. There have been done a research (Eurobarometer research 2009- How people feel patient safety aspects) where Estonia had results : • 45% of respondents considered it likely to get damaged during the hospital stay (EU average 50%) • 39% of Estonians answered that he/she or his/her family member has experienced a deviation (EU average 26%) • Estonians considered that the most important responsible entity of patient safety are healthcare professionals and hospitals. Although the opinion on whether patient safety is a problem in Estonian health care or not polarized, all experts agreed upon that some kind of further action should be taken. Health care in Estonia is not as safe as it should be - and can be. Picture 1. North Estonia Medical Centre main house in Mustamäe, Tallinn. 8 9
  6. 6. 2. CURRENT SYSTEM 1.5 To err is human Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. A number of studies have been done to investigate why deviations occur at all. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Thus, mistakes can best be prevented by designing the health system at all levels to make it safer--to make it harder for people to do something wrong and easier for them to do it right. Health care organizations must develop a “culture of safety” such that their workforce and processes are focused on improving the reliability and safety of care for patients. Safety should be an explicit organizational goal that is dem­ nstrated by strong leadership on the part of clinicians, executives, o and governing bodies. This will mean incorporating a variety of well-understood safety principles, such as designing jobs and working conditions for safety; standardizing and simplifying equipment, supplies, and processes; and enabling care providers to avoid reliance on memory. A large percentage of medical errors are associated with medications. The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following working definitions specifically for medication errors: For the field research we observed the daily routine of the hospitals workflow. Workflow in hospital is the set of tasks what are grouped chronologically into processes and every task needs the set of people or resources to accomplish a given goal. We noticed that one important issue what distract caretakers daily workflow is the information technology in hospital practice. Health IT, what must promise many benefits for improving quality and efficiency of health care service, seemed to be poorly functioning. Including unnecessary pauses and rework, delays, established workarounds, gaps where steps are often omitted, and a process that participants feel is illogical. Huge amount of time is spent on data entry to computers and its supposed to be only small detail of the many tasks that nurses are required to complete. Medication error: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, or systems including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. Picture 2. Nurse’s notebook, where she writes down doctors orders during morning wards round Common causes of medication errors: Ambiguous strength designation on labels or in packaging Drug product nomenclature (look-alike or sound-alike names, use of lettered or numbered prefixes and suffixes in drug names) Equipment failure or malfunction Illegible handwriting Improper transcription Inaccurate dosage calculation Inadequately trained personnel Inappropriate abbreviations used in prescribing Labeling errors Excessive workload Lapses in individual performance Medication unavailable Picture 3. Nursing file 10 Picture 4. Nurses workdesk 11
  7. 7. Health care is a service industry that relies heavily on good information. In closely following and taking care of patients, nurses are guardians of a rich source of information, but we found that some of this important information was documented in the nonofficial/ unrecordable notes or transferred as a conversations. The official report information seemed to be more overall assessments of patient care and includes only required information. There are some parts of information what are obligatory to be inserted digitally (Picture 4), but not all the information, what is recorded on paper files. There is reluctant attitude towards inserting information digitally - it is task that nobody wants to do it willingly. Because of searching information for every single patient from nursing files is inconvenient and time consuming, there are created so called “PAPKA” system- the piece of paper for each patient what is editable with pen and eraser (Picture 5). Current system at PERH hospital has both the paper and electronic records, and due to userhostile interface of both of these, there are used self created medication management system, with notebooks, handwritten lists, tables and notes. Picture 5. “PAPKA” There are gathered main information, what nurses needs more often- the quick and easy overview of all patients all together. Left side is for patient general information: name, ID code, doctors name, ward and place nr. Middle section is for marking down patients treatment plan for oral medicaments. Right section indicates intravenous medicaments. There are also remarks about patients menu preferences, date of operation and other main issues what are necessary to keep in mind. In the morning ward rounds nurse makes quick notes about doctors orders (Picture 2). Some departments then creates one more handwritten list with overall information about medicaments what must be daily prepared and distributed (Picture 6). As we concentrated our interest on drug distribution system, then we examined how information moves from doctors order in medical treatment plan until its execution. Everything has to be put down to the nursing file (Picture 3). Nursing file is a document what proofs the provision of nursing care to the patient, which consists of the following components: • general information about patient • medical history • the plan of nursing • monitoring the condition of the patient • the treatment plan • consultations All together makes a large number of paper records, what with opportunities of modern information technology are inadequate and poorly managed. Handling of these kind of paper files are time consuming and involves lot of workforce. Also there are need for physical space to storing them (Picture 7). Picture 7. All patients files are kept in these covers. Doctor signs all orders in this document. This is meant to be as a main working tool for nurses- for getting and gathering information. Picture 6. Medicine list and timetable on the wall of medicine cabinet 12 13
  8. 8. 3. CONCEPT 3.3 Mapping of information flow. 3.1 Need To start with, we mapped out the information flow during the daily routine in one hospital department (Picture 8). As a result of observing current medication administration system and taking under consideration background research what we presented in previous paragraphs, our team recognized a need to redesign this system at all levels to make it safer - to make it harder for people to do something wrong and easier for them to do it right. In health care system there should be a working culture what can prevent possible mistakes, doesn’t carry along errors what emerged in previous steps throughout all the process and avoid reliance on memory. In the situation where patients to nurses ratio is enormous, there should be avoided all the unnecessary working tasks. Another issue is the under-usage of information technology possibilities in hospital practice. Key Points for describing need : • prevent errors • save time • storing as much information as possible • convenient access of information • user-friendly interface for IT solutions • common operating environment for all levels of system • the integration of different working processes 3.2 General concept We found an opportunity for improvements. Our idea was to use benefits of info technological solutions, so that they are not inconvenient for users and maintain the benefits of existing system. We wanted to create a system that is as handy to use as notebook and pen, but is times more efficient. We took an iPad as a convenient tool with lot of possibilities and features as a base to our new system. We started creating a interface what is connected to a “smart” medicament distributing tray and at the same time allows to record digitally any kind of information at all levels of communication line. As far as we collect all the data in digital way its easy to transform it to all forms what are necessary in hospital system. Picture 8. Current information flow map We marked down all the key factors into a simple and clear order and got a blueprint what shows all the process and touch points (Pictures 9 and 10). Picture 9. Key figures 14 15
  9. 9. Explanations of error types on map: Mishearing: • misunderstanding of speech. Can hear wrong name, dose, type, quantity etc • can not hear properly because of some kind of disturbing factor Misinterpretation: • can interpret the heard information wrongly Writing error: • misunderstanding handwriting • cant write so quickly • somebody might disturb and then there can be blanks Timing error: • cant write so quickly • some information can be skipped due rush • to save time, nurse may not write everything down and hope to relay on her memory Medicine error: • disturbed when distributing medicines • open and prepare wrong medicine box • wrong amount • medicine mix up • patient mix up • mix up different time doses (morning pill amount goes to lunch blug etc) Picture 10. Processes and touch points blueprint Memory error: • don’t remember the order • dont remember on time As one of our main targets was to reduce error possibilities, we marked down the type of errors and the touch-points for them to possible rising up (Picture 11). Nurse writing everything down to nursing file Doctor saying instructions Nurse writing everything down to notebook Controlling error: • doctor controls (signs) only nursing file, not PAPKA what is the main working document Doctor signs Nurse writing everything to the “PAPKA” Possible mistakes: - mishearing misinterpretation writing error timing error medicine error memory error controlling error Nurse prepears medicines in medicine cabinet Nurse brings medicines to the patient Patient takes medicines Picture 11. Current information flow and error points 16 17
  10. 10. Automated Kanban System 3.4 Different existing concepts There are several existing high tech solutions for automated medicine dispensing systems worked out. We analyzed the pros and cons for all of them and tried to sort out good features. Cerner’s RxStation Cerner is innovative health care company that has developed quite unique automated medicine dispensing cabinet: RxStation. This cabinet allows hospitals to eliminate a source of potential human error. This cabinet is connected to each patient’s electronic medical record (EMR). When clinicians go to the cabinet to retrieve medications, they open the patient’s EMR and select the medication to be administered. A drawer on the RxStation cabinet containing the appropriate medication at the appropriate dose opens, allowing the clinicians to retrieve the medication. The tray and bin with the correct medication illuminates and unlocks. All other bins and trays are secured. RxStation consists of different modules that can be modified, added or removed to tailor it’s use for a given health system (2). Southwest Solutions Group have created another solution for better hospital inventory management. It is called A Two-Bin Automated Kanban System. It uses spacesaver’s Frame WRX and StockBox products. They say that Kanban helps to balance between not running out of medical supplies and managing inventory overhead cost. One main component of this system is StockBox (Picture 13) that uses RFID technology to automate medicine replenishment process. All the medical inventory is kept in open trays in Frame WRX (Picture 14). Picture 13. StockBox with RFID technology Picture 12. Cerner’s RxStation Picture 14. Frame WRX 18 19
  11. 11. 4.DESIGN KirbyLester Based on key-points of need, we decided to approach the problem from several angles and started to create two mutually complementary solutions: • MedBook application - easy to use interface for safer, quicker and more effective information administration • MedTray- what is connected through the dock to the MedBook app and supports nurses in medicine distribution, helping prevent errors and save time. Kirby Lester provides systems that feature the latest technology like built-in work-flow software, pharmacy management system interfacing, onscreen drug imaging, order history and tracking, reports, and other features previously only available on more expensive and complicated systems. Kirby Lester systems not only help improve counting accuracy and reduce labor time, but they also help to reduce and eliminate dispensing errors. 4.1 Interface of the App According to our blueprint we mapped out the App structure (Picture 17). Picture 15. Kirby Lester’s KL 100 pharmacy robot HD Medi ATDPS The Automatic Tablet Dispensing and Packaging System (ATDPS) is a fully-automatic, drug-specific, and patient-individual dose packaging system for strings of transparent sachets. The system can dispense, pack and print sachets for single or multiple doses, as well as mixed doses with all the important dose administration information. A maximum of 3600 drugs doses can be processed per hour for automatic dispensing to more than 1800 beds. The Special Tablet System (STS) is incorporated and allows the inclusion of special tablets in the production run. The system is compatible with all standard hospital information and patient administration systems. Authorization is conveniently handled using RFID (a unique radio frequency code) and provided that a user has appropriate access rights, the production can be managed. The trays used for the STS are also labeled with a RIFD chip, ensuring that only the right STS tray is accepted by the ATDPS (3). Picture 16. HD Medi ATDPS Picture 17. App structure 20 21
  12. 12. 03.01.2014 Fri Top menu Top menu contains four basic parts: • “morning tour” section which is later changeable to “patient” • medicine section • tests • food Additional feature is calendar, quick button to home page and login profile, search bar. We realize the importance of contact between nurse and doctor so we added contact feature and date. Left bar We use left sidebar structure and expanded menu, because it’s simple and very easy to control your logical location in the app. The buttons are designed in a way for easy understanding the relationship between each branch. When each button is pressed the visual map can help nurse avoid mistake. Right bar Right bar are quick access to clock reminder, notes taking, printing, save, setting and refresh. It can be dragged to the right to appear a board for above function. Content In the content there are basic information section about patient and their contact member. Notice section keeps update the recently important issue about patients messages and condition. Current information section contains medicine and food, it could be adjusted by finger for roll up and down to view all the information. In history section there is possible to change from calendar look to graph look, which improves the understandability and easy edit by clicking. It can show operation time, test time and temperature at the same time (Picture 18). So the nurse can have better knowledge of the patients condition whether it’s getting better or not. Patient Medicine Tests Food Patient Info Photo Contact Notice Name Sex Age Tele Adress Changing operation room Cloth washing is done Reminder 5min ago 1hour ago Building X in construction yesterday Name Relasion Tele Adress 08:00 10:00 Current Info -Medicine -Food Taking blood test 12:00 14:00 Taking medicine History 16:00 Recording Operation Test Temperature Get test result 18:00 20:00 22:00 Picture 19. Automated reminder 03.01.2014 Fri Patient Medicine Tests 03.01.2014 Fri Food Patient Medicine Building/Floor Building/Floor Patient Info Department/Unit Ward1 Name Photo Name Name Contact Ward2 Name Sex Age Tele Adress Changing operation room Cloth washing is done 5min ago 1hour ago Building X in construction yesterday Contact Ward2 Name -Food Name Relasion Tele Adress Changing operation room Cloth washing is done yesterday Food Breakfast A: Pulled Pork Sandwich,Steamed Carrots B: Cream Style Corn,Biscuit -Medicine Lunch A: Rosemary Roasted Potatoes,Sauteed Cabbage B: Sauteed Zucchini & Tomatoes Dressing A: Chicken Breast Tampico B: Shrimp & Sausage Jambalaya Name Name 5min ago 1hour ago Building X in construction Current Info Ward4 -Medicine Notice Name Sex Age Tele Adress Dinner Ward3 Current Info Name Photo Name Name Name Relasion Tele Adress Ward3 Ward4 Ward1 Name Food Patient Info Department/Unit Notice Tests -Food Ward5 Ward5 Name Name Ward6 Ward6 History Ward7 Ward8 Edit Recording Operation Test Temperature Save History Ward7 Ward8 Edit Recording Operation Test Temperature Visual map Visual map Picture 18. MedBook app’s patient page Picture 20. Food choosing window 22 23
  13. 13. We also add automated reminder (Picture 19) as backup during morning tour rush hour to reduce mistake as well as nurse’s stress of recording everything correctly in such a short time. 03.01.2014 Fri Patient Medicine Tests Food Patient Medicine Tests Food Friday 3.01 By clicking pencil button it will pop up a small window where the information is editable. For example if you want to edit food, it brings up a check list (Picture 20). Its very easy and timesaving to do just a few click and save. It automatically goes to the general system so kitchen gets all the information at the same time.
 Under food page (Picture 21), left bar gives the basic information about a day. Notice will show if there’s patient left who hasn’t chosen the food yet or any problem occur. When all is correct then “send” button will highlight so nurse can send all the list to the kitchen. Food list is arranged by ward, when a patient is not allowed to eat (for example in case of scheduled operation), it will automatically appears cross and it is not active for choices. Because there are other organizations involved in the food distribution, then it’s possible to create food lists also as a order for all the units and all patients, dinner, supper, etc (Picture 22). By clicking the triangle it is possible to arrange all the information in a way as it needs to be - date, building, department etc. It’s automatically calculates the total amount of certain types of food for a certain time.
 In the Medicine page (Picture 23) we use intelligent searching function at the top. If you insert “a” , then the database automatically provides the most possible choices. It turns to blue when it’s been chosen. Also there is possibility to search by category. By clicking on the second bar, the drop list will show all the general categories, and further it changes to the sublists. When item is chosen then it will turn to blue and the left column appears with its content. The list gives a warning when the medicine runs out of stock. By quick clicking there is possible to place an order for them from center pharmacy. Also you can add “favorites” to the search list. When patient list is chosen it will give all the information about certain medicine.
 03.01.2014 Fri Patient Medicine Tests Breakfast Lunch Dinner Food A Chicken Breast tampico Food B Shrimp & Sausage Jambalaya Notice Picture 22. Food page 03.01.2014 Fri Food Friday 3.01 W ard 1 Patient Food A Food B Remark W ard 5 Patient Breakfast ****** ****** Remark ****** Medicine List a ****** ****** Food B ****** Lunch Food A Dinner Food A W ard 2 Patient Food A Food B Remark W ard 6 Patient Food B Food B Remark W ard 7 Patient Fluoroquinolones Aminoglycosides Tuberculosis Food A Food B Fungal infections Remark ****** ****** ****** Malaria ****** ****** Otheranti-infectives ****** W ard 4 Drug Detail Viral infection ****** Notice dicloxacillin Tetracyclines ****** Food A penicillin v potassium Macrolides ****** Patient ampilicin susp Cephalosporins Remark ****** ****** Food A ****** ****** W ard 3 ampicillin caps Penicillines ****** Food B amoxil drops All Distribution ****** Chicken Breast tampico Shrimp & Sausage Jambalaya Patient List amoxicillin amoxicillin Patient Food A Food B Remark W ard 8 Patient ****** ****** ****** Remark ****** ****** Food B ****** ****** Short cut Food A ****** Picture 21. Food page + Add shortcut Picture 23. Medicine page 24 25 Order
  14. 14. 4.2 Appearance Step 1. Dock stays in medicine storage room. It also has a charging function. Picture 24. “MedTray” iPad dock Step 2. If placed to the dock, overall medicine distribution list opens. As there are need for distribution several times a day, then system automatically recognize a right time and shows a list for medicines what needs to be prepared. Picture 25. “MedTray” dock with iPad 27
  15. 15. Step 3. Placing the tray ontop of the lightpanel (Picture 26). Step 5. Holes are filled with paper cups (Picture 28). Picture 26. Picture 28. Step 4. System lights up holes for these patients who needs medications in this distribution time (Picture 27). Extra feature: we are using different colored cups for marking patients in ward (Picture 29)- we would like to suggest that in ward there are different places marked with different colors - bedsheets, cupboards, pijamas of patients or something else. Then its another proof that right medicine cup goes to right patient. Picture 27. Picture 29. 28 29
  16. 16. Step 6. Barcode reader window opens (Picture 30). Step 8. According to prescriptions right holes lights up. Amount of light dots indicates how many bills are needed to this cup (Picture 32). Picture 30. Picture 32. Step 7. Front camera reads barcode and detailed drug information appears (Picture 31). Step 9. After all necessary cups are filled, all lights are closed. Next step is inactive if there are some missing bills (Picture 33). Picture 31. Picture 33. 30 31
  17. 17. Step 10. The same procedure repeats with next medicaments from list until all needed are distributed (Picture 34). Picture 34. 4.3 Making a prototype for a MedTray Picture 36. Picture 37. Picture 38. Picture 39. Step 11. Medicaments are ready for distribution (Picture 35). Picture 35. 32 33
  18. 18. 4.4 Product value Med Book application would be working-tool for nurses that would be easy to use and due to this inserting and editing information would be easy and convenient. They would not need to do unnecessary tasks. If we compare “before” and “after” information flow maps, then it shows that most of the errors would be eliminated from the system after using MedBook together with MedTray. Not to mention the time what it would save and digitally recorded material what would be available for all levels of health care system. Benefits: • preventing errors • saves time • information is quickly editable and controllable • device is handy to use and portable • information is recorded digitally- allows easy transfers to other systems • information is in one common environment- available for all levels of system • all the records are quickly available and creates possibilities to quick analyses Nurse writing everything down to nursing file Doctor saying instructions Nurse writing everything down to notebook Doctor signs Doctor signs Nurse writing everything to the “PAPKA” Doctor saying instructions mishearing misinterpretation writing error timing error medicine error memory error controlling error Nurse prepears medicines in medicine cabinet Possible mistakes: Possible mistakes: - Nurse writing everything down to iPad Nurse prepears medicines in medicine cabinet Picture 40. Previous information flow map Nurse brings medicines to the patient Patient takes medicines - mishearing misinterpretation writing error timing error medicine error memory error controlling error Picture 41. New information flow map 34 35 Nurse brings medicines to the patient Patient takes medicines
  19. 19. 5. SUMMARY The implementation of modern information technology affects health care system heavily. The use of information technology in health and medical treatment improves the quality of service, as well as giving it the opportunity to significantly reduce the cost, which is related to the medical service. At the moment most health care institutions use different information systems, which are not able to exchange information with each other smoothly yet, but it is improving every day. As long as the use of a computer for everyday work is troublesome additional commitment for nurses there is amount of information what remains unsaved. We are sure that if the interface of device is convenient, then users will soon see it rather than the helping tool then a tedious extra duty. 6. REFERENCES 1. 2. 3. 36