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- 2. The Culture of Health Care Sociotechnical Aspects: Clinicians and Technology Lecture a This material (Comp 2 Unit 10) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 3. Sociotechnical Aspects: Clinicians and Technology Learning Objectives • Describe the concepts of medical error and patient safety (Lectures a, b). • Discuss error as an individual problem and as a system problem (Lecture a). • Compare and contrast the interaction and interdependence of social and technical “resistance to change” (Lecture c). • Discuss the challenges inherent with adapting work processes to new technology (Lecture c). • Discuss the downside of adapting technology to work practices and why this is not desirable (Lecture c). • Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety (Lectures a, b). 3
- 4. Focus of This Lecture • Medical errors and patient safety • Medical errors: Mistakes that occur during medical care • Patient safety: Reduction in patient harm • Reducing medical errors and improving patient safety are core aims of modern medicine 4
- 5. Medical Errors • A 1964 study by Schimmel, published in the Annals of Internal Medicine, reported that – 20% of patients admitted to a university hospital medical service suffered iatrogenic injury – 20% of those injuries were serious or fatal • In the United States, medical errors are estimated to result in 44,000 to 98,000 unnecessary inpatient deaths annually (Kohn et al., 1999) • A recent evidence-based study estimates the number of deaths resulting from medical errors is at least 210,000 and as high as 440,000 (James, 2013) 5
- 6. Adverse Events • Adverse events occur in all health care provider environments and in all nations • Data suggests a majority of these events occur in the hospital setting • Other areas are not immune to adverse events 6
- 7. Issues Facing Developing Nations • In developing countries, other significant issues contribute to errors: – Infrastructure and equipment are inadequate – Drug supply and quality are unreliable – Some health care workers may have insufficient technical skills due to inadequate training – Operating costs are often underfinanced 7
- 8. Types of Errors • Errors caused by individuals: – Unintended acts of omission or commission – Acts that do not achieve their intended outcomes • Errors caused by organizational systems: – Complexity of health care and health care technology – Complexity of disease and dependence on intricate clinical collaborations and interventions 8
- 9. History of Error Inquiry • Prior focus of inquiry for errors was on the individual and on the mistakes themselves – Investigations often reflected “name and blame” culture • Now the focus is on the system—fixing inadequacies in the system can improve patient safety – Focus on system allows individuals to perform their tasks in a patient-care-optimized environment 9
- 10. Individual Errors: Slips • Some errors, or “slips,” are unconscious • Usually, a “glitch” when performing repetitive, routine actions • Usually, attention is diverted, and there is an unexpected break in the routine • Attention can be impaired by many factors 10
- 11. Slips: Solving the Problem • Need to limit opportunities for loss of attention • Example: Sleep deprivation during resident training • Resident training in United States—limit the number of duty hours per week to reduce slips due to fatigue and sleep deprivation 11
- 12. Individual Errors: Mistakes • Some errors or “mistakes” are rule based or knowledge based – These are errors of conscious thought • Rule-based errors usually occur during problem-solving when a wrong rule is applied • Knowledge-based errors usually occur when the decision-maker confronts a novel situation 12
- 13. Mistakes: Solving The Problem • Rule-based errors – Use clinical decision support—order sets – Avoid bias in clinical reasoning • Knowledge-based errors – Improve knowledge at the point of care – Foster culture of collaboration and consultation 13
- 14. Organizational System Errors • System errors occur because of inadequacies in the system • Often committed by multiple individuals who intersect with patient care • Often difficult to analyze 14
- 15. Example: Medication Errors • Unintended changes in medications occur in 33% of patients at the time of transfer from one unit to another within a hospital • 14% of patients have unintended changes in their medications when they are discharged from the hospital • More than half of patients have at least one unintended medication discrepancy at hospital admission (Boockvar, et al., 2004) 15
- 16. Medication Reconciliation • Medication reconciliation: Process of avoiding unintended changes in medication across transitions in care • Requires iterative reviews of patient’s medications at different points of time during the hospital stay 16
- 17. Medication Reconciliation Continued • Methods for medication reconciliation: – Audit process across the medication ordering, fulfilment, and administration – Link process to computerized physician order entry (CPOE) and medication administration record (MAR) – Integrate medication reconciliation in the CPOE, pharmacy systems, MARs, and EHRs, – Have patients instead of clinicians reconcile their medications • Studies suggest reduction in errors but have not yet demonstrated improvement in outcomes 17
- 18. Who Is Driving Patient Safety Initiatives? • Clinicians • Hospitals • Regulatory bodies—for example, Joint Commission on Accreditation of Healthcare Organizations • Patients 18
- 19. Sociotechnical Aspects: Clinicians and Technology Summary– Lecture a • Focused on medical errors and patient safety • Distinguished slips from mistakes • Explored the concept of system errors • Examined the driving forces championing patient safety initiatives 19
- 20. Sociotechnical Aspects: Clinicians and Technology References – Lecture a References Agency for Healthcare Research and Quality. (2015). Medication errors, patient safety primer. Retrieved from https://psnet.ahrq.gov/primers/primer/23/medication-errors Agency for Healthcare Research and Quality. (2014). The patient safety and quality improvement act of 2005 (Public Law 109-41). Retrieved from http://www.ahrq.gov/policymakers/psoact.html Allen, Marshall. (2013). How many die from medical mistakes in U.S. hospitals? NPR. Retrieved from http://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical- mistakes-in-u-s-hospitals Auerbach, A., Landefeld, C., & Shojania, K. G. (2007). The tension between needing to improve care and knowing how to do it. New England Journal of Medicine, 357, 608–613. Boockvar, K., Fishman, E., Kyriacou, C., Monias, A., Gavi, S. Cortes, T. (2004). Original investigation. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and log-term care facilities. Archives of Internal Medicine. 2004;146(5):545-550. Retrieved from http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/216786 Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260, 1743–1748. Ebright, P. (2014). Culture of safety part one: Moving beyond blame. University of California. MERLOT. Retrieved from https://www.merlot.org/merlot/materials.htm%3Bjsessionid= F7A1AA5120282BC1123A261CCB3EEEDC?pageSize=&page=10&userId=19195 Grober, E. D., & Bohnen, J. (2005). Defining medical error. Canadian Journal of Surgery, 48(1), 39–44. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211566 James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3): 122–128. 20
- 21. Sociotechnical Aspects: Clinicians and Technology References – Lecture a Continued The Joint Commission Center for Transforming Healthcare and the Lifespan System. (2009). The wrong site surgery project. Retrieved from http://www.centerfortransforminghealthcare.org/UserFiles/file/CTH_Wrong_Site_Surgery_Project_ 6_24_11.pdf Kohn, L. T., Corrigan, J., McDonald, M. S., and Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Krumholz, H., & Lee, T. (2008). Redefining quality—Implications of recent clinical trials. New England Journal of Medicine, 358, 2537–2539. Leape, L. (2000). Institute of Medicine medical error figures are not exaggerated. JAMA, 284, 95–97. Leapfrog Group. (2013). Hospital errors are the third leading cause of death in U.S., and new hospital safety scores show improvements are too slow. Retrieved from http://www.hospitalsafetyscore.org /newsroom/display/hospitalerrors-thirdleading-causeofdeathinus-improvementstooslow McGlynn, E., Asch, S., Adams, J., et al. (2003). The quality of healthcare delivered to adults in the United States. New England Journal of Medicine, 348, 2635–2645. National Committee for Quality Assurance. (2016). The state of healthcare quality. Washington, DC: National Committee for Quality Assurance. Retrieved from http://www.ncqa.org/report- cards/health-plans/state-of-health-care-quality National Patient Safety Foundation. (2016). About. Retrieved from http://www.npsf.org/?page=aboutus Nolte, E., & McKee, C. (2008). Measuring the health of nations: Updating an earlier analysis. Health Affairs, 27, 58–71. 21
- 22. Sociotechnical Aspects: Clinicians and Technology References – Lecture a Continued 2 Patient Safety and Quality Healthcare (PSQH). Retrieved from http://psqh.com Pronovost, P., Ravitz, A., Stoll, R., & Kennedy, S. (2015). Transforming patient safety, a sector-wide systems approach. Report of the WISH patient safety forum 2015. Retrieved from http://cdn.wish.org.qa/app/media/1430 Schimmel, E. M. (1964). The hazards of hospitalization. Annals of Internal Medicine, 60, 100–110 Small, L. (2015). Global patient safety improvement effort needed. Fierce Healthcare. Retrieved from http://www.fiercehealthcare.com/story/global-patient-safety-improvement-effort-needed/2015-02- 17 Sox, H., & Woloshin, S. (2000). How many deaths are due to medical error? Getting the number right. Effective Clinical Practice, 6, 277–283. U.S. Food and Drug Administration. (2016). What is a serious adverse event? Retrieved from http://www.fda.gov/Safety/MedWatch/HowToReport/ucm053087.htm U.S. Food and Drug Administration. FDA Adverse Events Reporting System (FAERS) electronic submissions. Retrieved from http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugE ffects/ucm115894.htm World Health Organization (WHO). (n.d.). Patient safety. Retrieved from http://www.euro.who.int/en/health-topics/Health-systems/patient-safety WHO. (2009). WHO guidelines for safe surgery: safe surgery saves lives. Retrieved from http://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/ 22
- 23. The Culture of Health Care Sociotechnical Aspects: Clinicians and Technology Lecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 23
Editor's Notes
- No audio. Recording preparation.
- Welcome to The Culture of Health Care: Sociotechnical Aspects: Clinicians and Technology. This is Lecture a. The component, The Culture of Health Care, addresses job expectations in health care settings, including how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
- The objectives for Sociotechnical Aspects: Clinicians and Technology are to: Describe the concepts of medical error and patient safety Discuss error as an individual problem and as a system problem Compare and contrast the interaction and interdependence of social and technical “resistance to change” Discuss the challenges inherent with adapting work processes to new technology Discuss the downside of adapting technology to work practices and why this is not desirable Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety
- Unit 10 addresses the sociotechnical aspects of clinicians and technology. The sociotechnical systems approach recognizes the interaction between people and technology in workplaces as well as interaction between society’s complex infrastructures and human behavior. This lecture discusses medical errors and patient safety. Medical errors are mistakes that occur during medical care. Many of the errors that occur could have been prevented. A formal definition, according to Grober and Bohnen [bo-nen] (2005), describes a medical error as [quote]One, the failure of a planned action to be completed as intended (an error of execution) or the use of a wrong plan to achieve an aim (an error of planning); two, an unintended act (either of omission or commission) or one that does not achieve its intended outcome; or three, deviations from the process of care, which may or may not cause harm to the patient. [end quote] Patient safety refers to the fact that patients can be harmed as a consequence of errors, and they need to be protected against harm during health care delivery. Medical ethics emphasizes the concept of “primum non nocere [pree-mum non no-kay-rey],” which is Latin for “first, do no harm.” This is one of the fundamental ethical considerations that medical students are taught, and when they take the Hippocratic Oath as new physicians, they promise to “do no harm.” According to the World Health Organization, [quote] “The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care. While health care has become more effective, it has also become more complex, with greater use of new technologies, medicines, and treatments. Health services treat older and sicker patients who often present with significant co-morbidities requiring more difficult decisions as to health care priorities. Increasing economic pressure on health systems often leads to overloaded health care environments.” [end quote] Today’s trends and challenges require clinicians to keep patient safety at the forefront of all that they do, and reducing medical errors and improving patient safety are core aims of modern medicine.
- Medical errors have probably existed for as long as patient care and health care providers have been around. As far back as 1964, a study reported that twenty percent of patients admitted to a university hospital medical service suffered iatrogenic [eye-at-tro-jen-ick] injury, which means an injury caused by a medical procedure, and that twenty percent of those injuries were either serious or fatal. The 1999 landmark report from the Institute of Medicine, “To Err Is Human: Building a Safer Health System,” pointed out that medical errors in the United States are estimated to cause between forty-four thousand and ninety-eight thousand unnecessary inpatient deaths annually. One estimate has suggested that there may be as many as one million excess injuries each year as a consequence of medical errors. In the years since this report, medical error statistics continue to reflect the need to focus on reducing medical errors. A recent evidence-based study found in the Journal of Patient Safety estimates the number of deaths resulting from medical errors is at least 210,000 and as high as 440,000 (James, 2013). This would make medical errors the third-leading cause of death, behind heart disease and cancer. While advances in clinical therapeutics have undoubtedly resulted in major improvements in health for patients with many diseases, they have also been accompanied by increased risks. According to the Agency for Healthcare Research and Quality, or AHRQ, [quote] “An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly seven-hundred thousand emergency department visits and one-hundred thousand hospitalizations each year.” [end quote] ADEs affect nearly five percent of hospitalized patients, [quote] making them one of the most common types of inpatient errors; ambulatory patients may experience ADEs at even higher rates. Transitions in care are also a well-documented source of preventable harm related to medications. [end quote] Preventable medical errors are also a major global health concern that for too long has been accepted as inevitable, according to a 2015 report by the World Innovation Summit for Health.
- According to the Food and Drug Administration, [quote] “An adverse event is any undesirable experience associated with the use of a medical product in a patient.” [end quote] Adverse events can result, for example, in a life-threatening event; hospitalization (initial or prolonged); an emergency department visit or ambulatory provider visit; a patient disability or permanent damage. It’s reasonable to assume that adverse events occur in all health care settings, including nursing homes, long-term care facilities, emergency rooms, pharmacies, and even a patient’s own home, and they occur in all nations. The data suggests that most of these events occur in the hospital or inpatient setting, although researchers are unsure about the number of errors in the ambulatory setting because the data for outpatient events is often fragmented and incomplete.
- Developing nations have an increased burden when it comes to medical errors. In addition to the usual reasons for medical errors in developed countries, many developing nations face other significant issues, such as inadequate infrastructure and equipment, an unreliable drug supply and drug quality, and insufficient medical knowledge and technical skills of their health care workers because of inadequate training. Furthermore, operating costs are often underfinanced. All of these issues contribute to the likelihood of medical errors in health care infrastructures in developing countries.
- There are two fundamentally different types of errors. The first are errors caused by individuals; these may be unintended acts of omission or acts of commission. An example of an unintended act of omission is when a patient is transferred from one unit of the hospital to another and an important medication is left off the medication list. An example of an unintended act of commission is when a medication that is intended for one patient is delivered to another patient. Individual errors can also be acts that don’t achieve their intended outcomes. An example would be a misdiagnosis based on an error. The second main type of error is error caused within the environment of the provider organization. These system errors are a function of the complexities inherent in provider organizations, in health care technology, and in treating multiple disease situations, as well as of the dependence of the process of health care on a multiplicity of clinicians and interventions. The organizational environment includes the workflow, operational processes, and procedures found within a provider organization.
- The cause of errors must be identified so that they are not repeated. In the past, the primary focus of inquiry was on the individual who was felt to have committed the mistake and on the mistakes themselves. These investigations reflected the “name and blame” culture that existed in many health care systems, which punished those who committed errors. Instead of this approach, the focus is now on fixing inadequacies in the health care organization to improve patient safety. Correcting inadequacies may require changes in policies, procedures, workflow, and information systems as well as staff awareness and education. The focus on the health care organization allows health care providers to perform their tasks in an environment that is optimized to patient care rather than adversarial to the provider. The rationale for this approach is that good people make bad mistakes when they work with bad operational systems, and it makes much more sense to focus on the issue and fix the inherent problems than to place the entire blame on the shoulders of the individual who committed the mistake.
- Individual errors are also known as slips, and these are unconscious errors; they are usually a glitch when performing repetitive, routine, or complex actions. Slips are usually not thought based, and they occur when attention is diverted and there’s a break in the routine. Attention can be impaired by many factors, including fear, frustration, anger, and fatigue.
- How can health care systems reduce or eliminate individual errors or slips? One answer is to limit the opportunities for loss of attention. For example, sleep deprivation during physicians’ resident training is associated with an increased incidence of errors. After graduating from medical school, physicians undergo additional specialized training as residents. Residency is a concentrated learning experience in the clinical setting during which residents spend a protracted number of continuous hours delivering patient care; this leads to sleep deprivation and fatigue. The rules about resident training in the United States have been changed to limit the number of duty hours per week allowed for residents in order to reduce slips due to fatigue and sleep deprivation.
- Other types of individual errors or mistakes are rule based or knowledge based; these are errors of conscious thought. Rule-based errors usually occur during problem solving when the wrong rule is applied. These errors suggest an improper use of expertise. Knowledge-based errors usually occur when decision makers confront a novel situation that they have never experienced. The lack of expertise leads to an incorrect decision or a mistake.
- Rule-based errors can be addressed by using clinical decision support order sets; these may be incorporated into the electronic health record system to provide a layer of safety. Clinical decision support also allows clinicians to avoid bias in clinical reasoning. Knowledge-based errors can be reduced by improving the level of knowledge at the point of care. Knowledge can be embedded in the electronic health record and other clinical information systems; an example is information buttons. When clinicians have questions at specific points in their workflow, they can click on a button on the EHR interface that will display on the screen the level of knowledge that they require to complete their tasks. Knowledge-based errors can also be reduced by fostering a culture of collaboration and consultation; this is typically done by providing care in multidiscipline routines.
- In contrast to individual errors, organizational system and process errors occur because of inadequacies within the organization that delivers health care. They are often committed by multiple individuals who intersect while providing patient care within the same setting. System and process errors may occur at the same point of an individual workflow but may be committed by different clinicians; these errors are often difficult to analyze.
- Medication errors are one example of organizational system and process errors. It has been estimated that unintended changes in medications occur in about one-third of all patients at the time of transfer from one unit of a hospital to another. About fourteen percent of patients have unintended changes in their medications when they are discharged from the hospital, and more than half of all patients have at least one unintended medication discrepancy at hospital admission. Medication errors are therefore an enormous problem.
- How can health care systems reduce medication errors? One method is to implement a system of medication reconciliation, which is a process of avoiding unintended changes in medications across transitions in care. Medication reconciliation requires repeated reviews of a patient’s medications at the time of admission, at the time of transfer, and at the time of discharge. Also, it can include medication review or audit during a patient visit such as in an inpatient setting.
- Many different methods have been suggested for medication reconciliation to reduce medication errors. One method in the inpatient setting supports reconciliation of the physician’s medication orders with the pharmacy’s medication fulfilment and the patient’s medication administration record and EHR utilized by nursing staff. While medication is administrated by nursing staff and processed by the pharmacy department, physicians, physician assistants, and nurse practitioners with prescribing privileges are licensed to order or prescribe patient medications. Another method links the medication reconciliation process to computerized physician order entry, or CPOE. An additional information system included in the reconciliation process is the medication administration record (MAR), which is part of the patient’s legal medical record. The MAR is used by clinicians to document all drugs administered to a patient during his or her treatment at a provider. MARs are used by all providers and may vary slightly based on the needs of the specific provider type. Electronic versions may be called e-MARs. A third method integrates medication reconciliation into the user interface as a function of the patient’s EHR and MAR. Information systems provide the opportunity to utilize alerts and alarms from medication prescribing to fulfilling the order to medication administration to the patient. Information systems are tools clinicians can use to support medication administration and management while preventing unnecessary errors. Yet another suggestion is that the onus of medication reconciliation should be removed from clinicians and put in the hands of patients themselves; in other words, patients, not clinicians, should reconcile their medications. The increasing role of patient and family engagement in the patient’s care may advance this suggestion over time. Evidence suggests that medication reconciliation reduces errors. Ongoing research will hopefully prove that error reduction drives improved outcomes and increased patient satisfaction.
- This lecture has shown that patient safety is important and that individuals, systems, and provider organizations need to reduce or eliminate errors in the inpatient and outpatient settings and across the patient care continuum. Several entities are driving patient safety initiatives. Clinicians have taken a major role in providing safer health care, and so have hospitals. Regulatory bodies such as the Joint Commission have been instrumental in hospitals’ patient safety initiatives. Providers with Joint Commission accreditation include patient safety principles in their organizational policies and procedures. It’s also interesting to see that patients themselves have taken over some aspects of patient safety as a consumer phenomenon. The Joint Commission also participates in specific projects aimed at patient safety and reduction of medical errors. One such project is the Wrong Site Surgery Project, which [quote] “has the goal to improve the safeguards to prevent patients from wrong site, wrong side, and wrong patient surgical procedures.” [end quote] The World Health Organization has also published information around Safe Surgery project practices. According to the Agency for Healthcare Research and Quality, [quote] “The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41) was enacted in response to growing concern about patient safety in the United States and the Institute of Medicine’s 1999 report, To Err Is Human: Building a Safer Health System. The goal of the Act is to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients.” [end quote] The National Patient Safety Foundation, a not-for-profit 501(c)(3) organization, was formed in 1997 to create an environment [quote] “where patients and those who care for them are free from harm.” [end quote] NPSF partners with patients and families, the health care community, and key stakeholders to advance patient safety and health care workforce safety and to disseminate strategies to prevent harm. The publication “Patient Safety and Quality Healthcare (PSQH)” disseminates information written for and by people who are involved directly in improving patient safety and the quality of care. These are just a few examples of the many industry initiatives focused on the reduction of medical errors and the promotion of patient safety.
- This concludes Lecture a of Sociotechnical Aspects: Clinicians and Technology. In summary, this lecture focused on medical errors and patient safety, defined these terms, looked at issues facing the United States as well as developing nations, distinguished slips from mistakes, discussed the concept of system errors with examples, and examined the driving forces behind patient safety initiatives.
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