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Title: Patient Safety and Information Technology IT:


1
Patient Safety and Information Technology (IT)
  • Partners in Patient Care

VeHU 2008 Session 177 Tuesday July 15, 2008 330
PM 500 PM
2
HOUSE KEEPING
3
HOUSE KEEPING
  • This is 1.5 Hour lecture session
  • Restrooms are located
  • Cell Phones
  • Please turn off or change to vibrate
  • If you must answer a call, please leave the room.

4
HOUSE KEEPING
  • Please,
  • No questions during the presentation.
  • Questions written on the 3X5 card will be
    answered at the conclusion of the presentation.
  • For questions not answered,
  • the question and the answer will be available on
    the web.

5
Faculty
  • Office of Information (OI)
  • Health Data and Informatics (HDI)
  • Patient Safety Office (PSO)
  • Toni King, RN, BSN
  • Management Analyst
  • Joe Lucas
  • Management Analyst
  • Janine Purcell, M.S.I.E.O.R.
  • Cognitive Engineer

6
Learning Objectives
  • Describe the Health Data and Informatics (HDI)
    Patient Safety Office (PSO) vision, mission, and
    processes.
  • List patient safety issues in terms of human
    performance.
  • Explain examples of patient safety initiatives.
  • Identify the impact of data integrity and
    information management on patient safety.

7
Keeping Patients Safe Using IT Do No Harm
8
Vision
Veterans Health Administration (VHA) Office of
Information (OI) is committed to providing the
safest, most effective, and highest quality
software systems that support the delivery of
healthcare.
9
Mission
  • Patient safety is a continuous process that
    needs to be an integral component within
    healthcare delivery systems. Information
    technology has been recognized as a key factor in
    enabling healthcare facilities to have the
    ability to provide accurate and usable
    information to assist clinicians, nurses,
    pharmacists, allied health care professionals and
    other personnel that interact with and provide
    quality care to patients.

10
Mission (cont.)
  • The OI patient safety program will support the
    development and implementation of software
    application systems that focus towards
    improvement in safe, effective, quality health
    care, such that the following goals have been
    established

11
Goals
  • Define program objectives supported by personnel
    and budget.
  • Incorporate safety principles, using best
    practices such as user centered design based upon
    human factors engineering principles and
    standardized processes as well as incorporating
    usability testing into the development and
    pre-release evaluation process.
  • Implement a non-punitive system for reporting
    safety incidents as well as safety concerns with
    an ultimate emphasis on analysis in which to
    focus future development.
  • Establish training and teaching programs for
    existing and new staff to establish an
    organizational culture of safety.

12
History
  • National Center for Patient Safety (NCPS)
  • NCPS was established in 1999 to develop and
    nurture a culture of safety throughout the
    Veterans Health Administration. Their goal is the
    nationwide reduction and prevention of harm to
    patients as a result of their care
  • OI Health Data Informatics Patient Safety
  • In 2002 Office of Information (OI) recognized
    that Information Technology can have an effect on
    patient safety. They established a process to
    ensure that the electronic health record enhances
    patient care.
  • In 2005 -Hired full time Director, OI HDI Patient
    Safety who is a liaison between NCPS and OI
  • In 2007/ 2008 - Started staffing the OI HDI
    Patient Safety to provide needed expertise and
    support

13
Role of OI HDI Patient Safety
  • Foster a non-punitive system for reporting safety
    incidents as well as safety concerns with an
    ultimate emphasis on analysis in which to focus
    future development
  • Evaluate risk, determine recommended actions
  • Communicate necessary notification(s) to
    Veterans Administration Medical Centers

We dont fix the problem, we are A stimulus to
initiate discussion and a facilitator in having a
solution created.
14
Human Factors Engineering What it is and How its
helpful
15
Learning Objectives
  • Brief introduction to human factors principles
  • Human performance issues relevant to clinical
    settings

16
Human Factors Engineering

User-Centered Design
Designing Systems to fit human capabilities and
limitations AND the tasks that humans perform
in or with that system
17
Evolution of Human Factors
  • George Washington time and motion study of
    his farm operations
  • Frederick Taylor Time and motion studies in
    Industrial Age
  • Frank Gilbreth Motion study in surgery
  • World War II -- Aviation HF
  • The Age of Computers
  • Human Computer Interaction (HCI)

Time and motion studies record a chronology
of actions and time to complete those actions.
They are used as a tool for process improvement.
18
Why User Centered Design?
  • Safety principles early detection of potential
    problems before an adverse event occurs.
  • Cost benefits
  • allows for changes in User Interface early in
    life cycle, before time and resources have been
    expended.
  • increases the chance that the product will better
    meet end users needs.
  • Product effectiveness an intuitive user
    interface design will lead to more accurate and
    efficient product use.

19
Industry and Legislative Drivers for Human Factors
  • AAMI HE74 Human Factors Design Process for
    Medical Devices
  • AAMI HE75 Design Principles for Medical
    Devices
  • ISO 9241
  • Hardware and Software Ergonomic Standard
  • ISO 13407
  • Human Factors Enhancements to Software
    Development
  • Rehabilitation Act Amendments of 1998 (Section
    508)

20
Human Systems Model
21
Culture
22
Environment
23
Tools for BCMA
Eyes and Ears Memory Cognition Body
BCMA Software Medication Carts Bar Code
Scanners PYXIS Pill crushers
24
Tasks
  • Nurse on med pass regenerates missed meds report
    several times during the med pass on the computer
    and checks it onscreen
  • By doing this she updates her checklist of
    remaining patients (Situational Awareness)
    Acute Psych 23 patients for that med pass

25
A Human Factors Framework
  • What do people do?
  • Sense
  • Perceive/assume/interpret/think
  • Store information in memory
  • Retrieve information from memory
  • Decide how to respond
  • Respond

26
(No Transcript)
27
  • MZALB
  • ZYP
  • JCEFT
  • SUWRG
  • TPJOM
  • XCIDB
  • GCUFI
  • WOPR
  • BGLDA

LAALK OEWSI GCUFI TPJOM JCEFT SUWRG TPJOM XCIDB J
DIEL
28
BLUE RED GREEN WHITE BLUE RED YELLOW WHITE YELLOW
RED BLUE WHITE GREEN BLUE RED WHITE YELLOW GREEN
29
Automatic Processing Versus Controlled Processing
(Preece, 1994)
  • Automatic processes unaffected by memory limits
  • fast
  • demand minimal attention
  • not available to consciousness
  • Controlled processes require attention and
    conscious control

30
A Human Factors Framework
  • What do people do?
  • Sense
  • Perceive/assume/interpret/think
  • Store information in memory
  • Retrieve information from memory
  • Decide how to respond
  • Respond

31
Mind as Tool Multi-store Model of Memory
(Preece, 1994)
  • Sensory store
  • Specific to sense
  • vision less than a second
  • hearing several seconds
  • Working memory
  • information actively being worked on
  • Millers Magic Number 7 /- 2
  • Permanent long term memory

32
Designing to improve decision making
  • Cognitive aids
  • Optimal screen design
  • Density
  • Layout
  • Smart displays
  • Consolidating the data needed to make a clinical
    decision
  • Checklists, electronic or paper-based

33
Speed / Accuracy Tradeoff
  • Cognitive speed bumps
  • Removal of data field autofill
  • Confirmatory or mandatory fields

34
Human Memory Model Working Memory (Mayhew, 1992)
  • Working memory is where people
  • perform calculations
  • interpret incoming data
  • juggle information as they solve problems
  • Sustained attention is required to maintain
    contents of working memory
  • Interruptions hasten the degradation of
    information in working memory, especially as
    interruptions become more complex

35
Limited resources are a cognitive reality
36
Solutions must come from the nursing team
  • Vest for Med Pass
  • DRUG ROUND IN PROGRESS
  • PLEASE DO NOT INTERRUPT AS MISTAKES CAN COST
    LIVES

37
A Human Factors Framework
  • What do people do?
  • Sense
  • Perceive / assume / interpret / think
  • Store information in memory
  • Retrieve information from memory
  • Decide how to respond
  • Respond
  • Interact in a social environment
  • Learn (teach and communicate)

38
How to respond
  • When I say up, everyone raise your hand up as
    quickly as you can
  • Then put it right back down as quickly as you can

39
Medical Software Example
40
Automatic Processing Versus Controlled Processing
(Preece, 1994)
  • Automatic processes unaffected by memory limits
  • fast
  • demand minimal attention
  • not available to consciousness
  • Controlled processes require attention and
    conscious control
  • Automatic processes difficult to unlearn once
    they have become automatic themselves
  • function key assignments, consistent screen
    locations

41
Volunteer to write instructions
  • Starting from
  • Jar of Peanut Butter
  • Bag of Bread
  • Plate and butter knife
  • Ending with two slices of bread and peanut butter
    on plate

42
Self Disclosure How it Helps
43
When Things Go Wrong
  • In the report To Err is Human Building a
    Safer Health System, the Institute of Medicine
    estimated that as many as 98,000 hospitalized
    Americans die each yearnot as a result of their
    illness or disease but as a result of errors in
    their care (IOM, 2000)

44
When Things Go Wrong (cont.)
  • Data inventory is key.listening to the
    people in your administration, talking to your
    administration, talking to focus groups of
    patients and talking to clinicians. The most
    extraordinary question we ever asked our staff
    was, What do you lie awake at night worrying
    about? The list they came up with is massive,
    full of the things that could fail or go wrong.
  • James Conway, MS, COO
  • Dana-Farber Cancer Institute
  • In Reducing Medical Errors, Improving Patient
    Safety Taking the Next Step, Health Leaders
    Roundtable, June 2001.

45
Why Report IT Safety issues
  • Good for patients and staff
  • Learning opportunity
  • Improves safety through feedback
  • Build organizational memory on what happened and
    why
  • Communicate organization concerns about IT issues
  • Aids in correcting vulnerabilities

46
Role of the OI HDI Patient Safety
  • Direct and Indirect Partnerships
  • Patients
  • Business owners
  • NCPS
  • Medical Centers
  • End Users
  • Analysts
  • Support staff
  • IT specialists

47
OI HDI Patient Safety
  • Provides a critical look at all issues
  • Data analysis
  • Interviews - (storytelling)
  • Research
  • Remedy tickets
  • Past Electronic Error and Enhancement Report
    (E3R)
  • Clear Quest database
  • NCPS (SPOT) database
  • Review literature
  • Regulatory organizations
  • RCA, HFMEA, Focus Groups
  • Participate with various workgroups

48
Focus on IT Patient Safety
  • Reportreportreport
  • Engaging senior leadership
  • Involve front end users
  • Use available Information Technology tools

49
What VA Staff Can Do to Promote a Culture of IT
Patient Safety
50
Promoting IT Patient Safety
  • Engage patients
  • Understand how the environment of care can impact
    patient safety
  • Look for anomalies and potential problems
  • Report IT near misses/close calls
  • Improve Communication
  • Automate tasks that are likely to cause errors
  • Reduce interruptions
  • Intervene when problems are detected
  • Culture of vigilance

51
  • Key Learning from the Dana-Farber Cancer
    Institutes 10-Year Patient Safety Journey
    Al-American Society of Clinical Oncology 2006
    Education Book P.617 James Conway et al.

52
Sustaining a Culture of IT Patient Safety
  • Everyone in your organization needs to know they
    play an important role in patient safety.
  • Leadership Support
  • Non-punitive Error Reporting

53
Solutions Must Include the End User Perspective
54
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55
Learning Objectives
  • Solutions must include end user perspectives

56
Evaluating a Procedure
57
Usability evaluation
  • Learned intuition and assumptions
  • Stereotypes
  • Metaphors
  • Iterative evaluation with the human processor
    is how to debug

58
  • What ignites usability?

59
What ignites usability?
  • Usefulness
  • Efficiency
  • Ease of learning
  • Ease of remembering
  • User satisfaction

60
How do we increase the usability of our world?
61
High level tactics
  • Involve end users as early as possible in the
    design of new systems, processes, and tools
  • Integrate human factors knowledge into product
    and process design

62
Usability Evaluation
  • Gathering data about the usability of a design
    or product by a specified group of users for a
    particular activity within a specified
    environment or work context.
  • Preece, 1995
  • Somebody doing something, somewhere


63
Human Factors Engineering initiatives in VHA
Information Technology
  • CPRS Lab status information display Informed
    Consent software
  • CCOW
  • BCMA software development and evaluation
  • Bar code expansion
  • Medication carts
  • Human factors education

64
Examples of User Evaluations
  • Distributed user evaluations (green lights
    assessment)
  • Remote user evaluations with telephonic
    interviewing
  • Scenario-based usability testing
  • Face-to-Face
  • Onsite observation and interviewing

65
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66
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67
Code Blue Software Prototype
  • User workgroup
  • Screen design principles
  • Terminology
  • Icons versus labels
  • Usability Evaluation
  • Mock code blue
  • Real staff
  • Script

68
Computerized Medication Carts
69
Medication cart evaluation
  • Published internal Recommendations advocating
    assessment of computerized medication cart
    equipment in the actual work setting using actual
    work tasks
  • Steerability is a prime concern and requires
    cart be loaded and steered through actual
    physical environment in actual workflow to
    adequately assess it
  • Ergonomic issues such as height adjustability for
    range of staff
  • Utility of cart features such as work surface,
    storage capacity, custom accessories
  • Challenges arise from government procurement
    cycle and contracting rules

70
To recap
  • Solutions must include the end user perspective

71
Examples of Patient Safety IT Initiatives
72
  • Improving safety and quality is a team sport.
    The "dream team" consists of the best clinicians,
    the best people in IT, and the best systems that
    integrate them. It won't be easy, but that's the
    ultimate goal of the system we want to create for
    ourselves.
  • Dr.
    Carolyn Clancy, M.D., Director, AHRQ

73
PSI-07-227
  • Issue- Remedy Help Desk220858 11/27/07 The
    wrong drug was filled and dispensed by Parata
    robot for 3 Rxs when VistA HL7 RXD segment sent
    incorrect NDC numbers for the Rxs
  • Flagged as PSI on 11/29/2007
  • PSO analysis starts 11/29/07
  • PSI discussed on the PSWG 12/13/07

74
PSI-07-227 (cont.)
  • PSI Scored by PSWG
  • Severity 1Minor
  • 4Catastrophic
  • Frequency 3Occasional
  • Detectability4remote
  • __________________
  • Total Score 48

75
PSI-07-227 (cont.)
  • Scoring guidelines for follow up Actions
  • Greater than 24 Solution to address the
    reported risk must be included in first available
    software release. (i.e. a patch must be
    created immediately or a current patch under
    development must be adjusted to include the
    solution)
  • If unable to provide a software solution in
    current version, a detailed plan of action must
    be provided. (i.e. inclusion in current
    version would be prohibited due to current
    product architecture, however, a software
    solution can be adapted into future software
    architecture)
  • http//vaww.vhaco.va.gov/HDI/oipatientsafety.asp

76
PSI-07-227 (cont.)
  • Development finds the source of the problem
  • Series of meetings to discuss the problem and the
    solution (fix).
  • Emergency patch (disable VistA speed renewal
    function) released 4/1/08
  • Permanent solution scheduled for release 6/1/08

77
Example Two of Patient Safety IT Initiatives
As soon as you see a mistake and don't
fix it, it becomes your mistake.

78
Free-text Allergy Issue
  • Free-text allergy entries in CPRS do not
    generate automatic drug-allergy order checks
    necessary for effective medication management.
    Patients with a known allergy may be administered
    a medication or served a food product for which
    they could have a severe reaction.

79
Free-text Allergy Issue
  • In June 2007, a software utility (GMRA429)
    was provided to automate mapping of existing
    free-text patient allergy entries to standard
    entries.

80
Free-text Allergy Issue
  • Remaining free text allergy entries were either
    too ambiguous to be reliably mapped, or may
    contain multiple reactants.
  • Examples
  • Misspelled - Penacillin
  • Combined items Tylenol with Codeine
  • Assorted Other entries - Misc. Molds

81
Free-text Allergy Issue
In January 2008 The OI HDI Patient Safety Office
in conjuction with the National Center for
Patient Safety issued a Patient Safety Alert
requiring that the remaining free text allergy
entries be resolved.
82
Discuss Impact of Data Integrity on Patient Safety
83
Data Integrity
  • The causes of medication errors are
    miscommunication, miscalculations,
    workload/staffing problems, interruptions,
    increases in knowledge and technology demands and
    incomplete documentation
  • (IOM, 2004b)

84
Data Integrity
  • Roadmap for charting delivery of care
  • Used for decision making and patient response to
    therapy
  • Assist as a reference to recall information
    during handoff
  • Used for historical information
  • Used for performance improvement
  • Staff and patient education
  • Joint Commission readiness
  • Used for litigation

85
Documentation
  • If it wasnt charted it wasnt done

86
Documentation
  • Document at the time or soon as possible (Humans
    are good at recognizing, poor at recall)
  • Avoid accepting verbal orders without proper
    documentation
  • Be vigilant with documentation-use cognitive
    cues, checklist and other job aids to ensure all
    medications and other care are documented in a
    timely manner
  • Ensure documentation reflects the time actions
    were carried out

87
  • Computers and information systems can make
    important fundamental contributions toward
    creation of safe systems through improving access
    to information, reducing reliance on memory,
    increasing vigilance, and contributing to
    standardization of processes.

  • Kilbridge and Clasen

  • JAMIA, April 2008


88
Summary
  • OI HDI Patient Safety mission, vision and
    possesses
  • Patient safety and human performance
  • Role of staff in IT patient safety
  • Examples of IT patient safety initiatives
  • Impact of data integrity and information
    management on patient safety

89
Patient-Centric IT Care
90
  • Thank you for attending this education session
  • Please refer question to the OI HDI Patient
    Safety Office team
  • via e-mail
  • VHA OI HDI Patient Safety
  • Have a SAFE and enjoyable stay in Tampa

91
Acronyms
92
Web Sites - User Centered Design Societies
  • Human Factors and Ergonomics Society (HFES)
  • http//www.hfes.org/
  • The Usability Professionals Association (UPA)
  • http//www.upassoc.org/index.html
  • ACM-Special Interest Group on Computer-Human
    Interaction (SIGCHI)
  • http//sigchi.org/
  • Society for Technical Communications (STC)
  • http//www.stc.org/chapter_search.asp

93
Other Learning Links
  • FAA Human Factors ONLINE Training
  • http//www.hf.faa.gov/Webtraining/index.htm
  • Human Computer Interaction Bibliography
  • Extensive Links to academic researchers and other
    human computer interaction resources
  • http//www.hcibib.org/education/

94
Other Learning Links
  • http//www.usableweb.com/
  • http//usability.gov/
  • http//www.edwardtufte.com/
  • http//www.moma.org/exhibitions/2005/safe/
  • http//www.idsa.org/IDEA2007/gallery/index.htm

95
Bibliography
  • Denning, S. (2005). The Leaders Guide to
    Storytelling Mastering the Art and Discipline of
    Business Narrative. New York John Wiley
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  • Dumas, J. and Redish, G. (1993). A Practical
    Guide to Usability Testing. Norwood, NJ Ablex.
  • Hackos, J and Redish, J. (1998). User and Task
    Analysis for Interface Design. New York John
    Wiley Sons, Inc.
  • Kuniavsky, M. (2003). Observing the User
    Experience A Practitioners Guide to User
    Research. San Francisco Morgan Kaufmann.

96
Bibliography
  • McLaughlin, R. (2003). Hospital Extra
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  • Preece, J., et al. (1994). Human Computer
    Interaction. Boston Addison Wesley.

97
Bibliography
  • Rogers, E.M. (1995). Diffusion of Innovations.
    New York Free Press.
  • Rubin, J. (1994). Handbook of Usability Testing.
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  • Sawyer, D. (1996). Do It By Design. Us
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98
Bibliography
  • Tufte, Edward (1997). Visual Explanation.
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