Effective Clinical Systems
An organization can encourage open and honest communication and foster teamwork but still have safety issues if the systems through which care is provided do not ensure protection against error. Highly trained, skilled individuals who work as a team and communicate still make mistakes. In the complex medical care environment, human factors such as fatigue, interruptions, and distractions can cause even the most talented and dedicated practitioners to err; and human nature can lead these practitioners to sometimes take the path of least resistance. Because human performance, by definition, is not perfect, the concept of error management through structured systems is an important one.
Knowing that people will make mistakes allows for systems to be engineered in such a way that the errors are trapped and do not become consequential.
Errors in medicine are not only caused by humans. Often, poor system design incorporates certain latent failures that can set up the individuals providing care to fail.
DESIGNING GOOD SYSTEMS
Following are some tips on how to design effective systems:
Have simple rules. Complex environments are best handled by simple rules; thus, the rules of any system should be easy to understand and follow.
Offer consistency and predictability. Systems should provide staff with a common foundation on which to approach the work.
Feature redundancy. Redundancy offers multiple layers of defense from error. If the system fails in one area, a redundant function helps mitigate the effects of the failure. In other words, redundancy allows the system to fail benignly.
Incorporate forcing functions. A forcing function is a mechanism that makes it easy to do the right thing and hard to do the wrong thing. For example, in aviation, an airplane’s bathroom doors are equipped with a forcing function: an individual cannot turn the light on in the bathroom without locking the door first. An example in medicine is a computerized medication system that does not let a nurse give an incorrect dose of a particular medicine. Other examples are tubing designs that prevent oral feedings from being connected to intravenous ports or a computer system that does not allow an order to be executed without key fields being completed in an order entry.
Ensure that people cannot work around the system. Prohibiting system work-arounds is especially important if no forcing functions are in place in a system. Understanding why individuals are developing work-arounds is the first step toward eliminating them and developing better systems.
Minimize reliance on human memory. The demands of providing clinical care can overwhelm the resources of skilled individuals. Thus, effective systems do not rely on these individuals to remember what to do and when to do it. Examples include having dosing information available at the point of prescribing or administering and having patient allergy information in a readily retrievable place in the chart.
Allow the expertise of the people performing the work to be used. While protocols are important, good systems also allow clinicians to use their best judgment when an unusual situation arises. For example, a standardized protocol to give antibiotics to prevent surgical site infections provides a systematic approach to this task every time, so patients reliably receive the correct care. However, if the experts overseeing the care of a patient feel the need to depart from the protocol on the basis of their clinical judgment, that should be allowed.
Incorporate technology where possible. Computers, electronics, and automation can offer distinct advantages when designing systems. Organizations that capitalize on the latest technology can improve the reliability of systems while making procedures easier and faster.
Communicate the advantages of the system to clinicians. Effective systems should be designed in a way that meshes well with the skills and behaviors of people providing the care. However, if staff do not see clear advantages to a system, they will likely work around it. Why would a physician use the computer to order medications if it takes three times as long as writing prescriptions by hand? The advantages of the system should be communicated, and the design must ensure that disadvantages are minimized.
Consider what happens if the system fails. Determining in advance the implication of system failures is time well spent. If a new anesthesia machine, for example, is completely electronic, what happens if the computer crashes in the middle of anesthetizing a patient? Being prepared for such an occurrence helps ensure a safe response.
EXAMPLES OF SYSTEMS
Surgical Infection Prevention Project
The Surgical Infection Prevention Project is based on the systematic implementation of the following four evidence-based interventions:
1. Timely administration of prophylactic antibiotics to maximize their benefit in reducing infection. Antibiotics are prepared for administration in the preoperative holding area with a reminder mechanism for anesthesiologists to ensure that patients receive prophylactic antibiotics within one hour of surgical incision.
2. Tight control of blood glucose levels in the perioperative period to lower infection rates. This intervention is based on evidence in cardiac surgery patients that showed fewer sternal wound infections when blood glucose levels were kept under 200 mg dl (Golden et al. 1999). High levels of adrenalin, which lead to increased blood glucose levels, are normal around the time of surgery, reflecting the physiologic stress the patent is experiencing. An additional component to this intervention relates to diabetic patients who undergo surgery. Blood glucose is measured in diabetic patients preoperatively and upon arrival in the recovery room. Standardized protocols for insulin infusions are used in patients requiring control. Recently, the Portland protocol was developed, which requires an intravenous insulin drip to be given to all diabetic cardiac patients for three days before and after surgery to reduce their level of blood sugar (Furnary et al. 2003). According to one study, the use of the Portland protocol can cut the mortality rate of
diabetic cardiac patients in half (Libby 2004).
3. Maintenance of normal body temperature during surgery. The patient’s temperature is maintained at 36 degrees centigrade or higher to keep skin blood vessels from constricting in response to cold. The logic behind this intervention is that warm patients have better perfusion (or blood flow) through the surgical wound and muster a better immune response to prevent bacterial contamination. Heating patients through IV fluid warmers, warming blankets, and
heated airway gases are effective mechanisms to accomplish this.
4. Use of supplemental oxygen after surgery to increase the oxygen levels in the wound. Patients receive high levels of supplemental oxygen (100 percent nonrebreathing face masks) for two to three hours postoperatively. A European study showed lower rates of infection in patients undergoing colon surgery in the group given high levels of oxygen postoperatively (Greif et al. 2000). Having a standard protocol by which patients automatically receive this treatment is far more effective than relying on human memory.
High-Tech Solutions
Computerized Physician Order Entry
Medication error is the most common source of medical error and patient injury (Cesar, Briceland, and Stein 1997). Some 40 percent of medication errors are caused by cognitive mistakes on the part of the prescribing physician, and illegible handwriting accounts for another 25 percent (Cesar, Briceland, and Stein 1997). A computerized physician order entry (CPOE) system addresses these and other issues in the following ways:
It ensures that orders are legible and complete, because they are entered into the computer and no longer written out by hand.
It prevents prescribing errors such as wrong dose, wrong drug, and wrong schedule of administration. CPOE programs have forcing functions that help ensure that the correct dosage range is administered on the correct schedule. For example, the CPOE system at the Brigham and Women’s Hospital in Boston automatically searches for the most recent measure of kidney function for drugs that are dependent on renal elimination, and it prompts the physician to
order one if it is not present (Bates et al. 1998).
It identifies allergies and drug interactions. CPOE systems store allergies and screen for adverse drug interactions. These systems need to be calibrated to warn users of more serious interactions, because if they alarm too frequently over issues seen as insignificant, then the warnings are more likely to be ignored.
Bar Coding
Bar coding can be used in medicine to help identify patients and ensure that the correct medication or test is being administered to the correct patient.
Bar coding has several advantages in identifying patients. It can not only match the correct medication with the correct patient, but it can also eliminate reliance on verbal identification and avoid misinterpretation in situations involving language differences and communication barriers, such as hearing difficulties and literacy issues.
Automated Dispensing Machines with Medication Profiles
Automated dispensing machines can be effective in decreasing turnaround time, limiting access to medications, and, when combined with bar-code technology, decreasing errors and their harmful results. Access to medication is limited to only those medications that are present in the pharmacy profile, that is, medication orders that have been reviewed by pharmacists and added to the patient’s electronic profile. Nurses are able to override the system in specific circumstances when patient care may be compromised by a delay.
Smart Pumps
New pump technology, which is referred to as “smart pumps,” not only offers safeguards to prevent IV solutions from flowing into a patient without control but also contains a formulary database that alerts nurses when the flow rate selected will result in a dose that could harm the patient.
For more Information:
* Healthcare Management, Healthcare Strategy, Lean Healthcare, Healthcare Management Books. Safe and Reliable Healthcare. *
An organization can encourage open and honest communication and foster teamwork but still have safety issues if the systems through which care is provided do not ensure protection against error. Highly trained, skilled individuals who work as a team and communicate still make mistakes. In the complex medical care environment, human factors such as fatigue, interruptions, and distractions can cause even the most talented and dedicated practitioners to err; and human nature can lead these practitioners to sometimes take the path of least resistance. Because human performance, by definition, is not perfect, the concept of error management through structured systems is an important one.
Knowing that people will make mistakes allows for systems to be engineered in such a way that the errors are trapped and do not become consequential.
Errors in medicine are not only caused by humans. Often, poor system design incorporates certain latent failures that can set up the individuals providing care to fail.
DESIGNING GOOD SYSTEMS
Following are some tips on how to design effective systems:
Have simple rules. Complex environments are best handled by simple rules; thus, the rules of any system should be easy to understand and follow.
Offer consistency and predictability. Systems should provide staff with a common foundation on which to approach the work.
Feature redundancy. Redundancy offers multiple layers of defense from error. If the system fails in one area, a redundant function helps mitigate the effects of the failure. In other words, redundancy allows the system to fail benignly.
Incorporate forcing functions. A forcing function is a mechanism that makes it easy to do the right thing and hard to do the wrong thing. For example, in aviation, an airplane’s bathroom doors are equipped with a forcing function: an individual cannot turn the light on in the bathroom without locking the door first. An example in medicine is a computerized medication system that does not let a nurse give an incorrect dose of a particular medicine. Other examples are tubing designs that prevent oral feedings from being connected to intravenous ports or a computer system that does not allow an order to be executed without key fields being completed in an order entry.
Ensure that people cannot work around the system. Prohibiting system work-arounds is especially important if no forcing functions are in place in a system. Understanding why individuals are developing work-arounds is the first step toward eliminating them and developing better systems.
Minimize reliance on human memory. The demands of providing clinical care can overwhelm the resources of skilled individuals. Thus, effective systems do not rely on these individuals to remember what to do and when to do it. Examples include having dosing information available at the point of prescribing or administering and having patient allergy information in a readily retrievable place in the chart.
Allow the expertise of the people performing the work to be used. While protocols are important, good systems also allow clinicians to use their best judgment when an unusual situation arises. For example, a standardized protocol to give antibiotics to prevent surgical site infections provides a systematic approach to this task every time, so patients reliably receive the correct care. However, if the experts overseeing the care of a patient feel the need to depart from the protocol on the basis of their clinical judgment, that should be allowed.
Incorporate technology where possible. Computers, electronics, and automation can offer distinct advantages when designing systems. Organizations that capitalize on the latest technology can improve the reliability of systems while making procedures easier and faster.
Communicate the advantages of the system to clinicians. Effective systems should be designed in a way that meshes well with the skills and behaviors of people providing the care. However, if staff do not see clear advantages to a system, they will likely work around it. Why would a physician use the computer to order medications if it takes three times as long as writing prescriptions by hand? The advantages of the system should be communicated, and the design must ensure that disadvantages are minimized.
Consider what happens if the system fails. Determining in advance the implication of system failures is time well spent. If a new anesthesia machine, for example, is completely electronic, what happens if the computer crashes in the middle of anesthetizing a patient? Being prepared for such an occurrence helps ensure a safe response.
EXAMPLES OF SYSTEMS
Surgical Infection Prevention Project
The Surgical Infection Prevention Project is based on the systematic implementation of the following four evidence-based interventions:
1. Timely administration of prophylactic antibiotics to maximize their benefit in reducing infection. Antibiotics are prepared for administration in the preoperative holding area with a reminder mechanism for anesthesiologists to ensure that patients receive prophylactic antibiotics within one hour of surgical incision.
2. Tight control of blood glucose levels in the perioperative period to lower infection rates. This intervention is based on evidence in cardiac surgery patients that showed fewer sternal wound infections when blood glucose levels were kept under 200 mg dl (Golden et al. 1999). High levels of adrenalin, which lead to increased blood glucose levels, are normal around the time of surgery, reflecting the physiologic stress the patent is experiencing. An additional component to this intervention relates to diabetic patients who undergo surgery. Blood glucose is measured in diabetic patients preoperatively and upon arrival in the recovery room. Standardized protocols for insulin infusions are used in patients requiring control. Recently, the Portland protocol was developed, which requires an intravenous insulin drip to be given to all diabetic cardiac patients for three days before and after surgery to reduce their level of blood sugar (Furnary et al. 2003). According to one study, the use of the Portland protocol can cut the mortality rate of
diabetic cardiac patients in half (Libby 2004).
3. Maintenance of normal body temperature during surgery. The patient’s temperature is maintained at 36 degrees centigrade or higher to keep skin blood vessels from constricting in response to cold. The logic behind this intervention is that warm patients have better perfusion (or blood flow) through the surgical wound and muster a better immune response to prevent bacterial contamination. Heating patients through IV fluid warmers, warming blankets, and
heated airway gases are effective mechanisms to accomplish this.
4. Use of supplemental oxygen after surgery to increase the oxygen levels in the wound. Patients receive high levels of supplemental oxygen (100 percent nonrebreathing face masks) for two to three hours postoperatively. A European study showed lower rates of infection in patients undergoing colon surgery in the group given high levels of oxygen postoperatively (Greif et al. 2000). Having a standard protocol by which patients automatically receive this treatment is far more effective than relying on human memory.
High-Tech Solutions
Computerized Physician Order Entry
Medication error is the most common source of medical error and patient injury (Cesar, Briceland, and Stein 1997). Some 40 percent of medication errors are caused by cognitive mistakes on the part of the prescribing physician, and illegible handwriting accounts for another 25 percent (Cesar, Briceland, and Stein 1997). A computerized physician order entry (CPOE) system addresses these and other issues in the following ways:
It ensures that orders are legible and complete, because they are entered into the computer and no longer written out by hand.
It prevents prescribing errors such as wrong dose, wrong drug, and wrong schedule of administration. CPOE programs have forcing functions that help ensure that the correct dosage range is administered on the correct schedule. For example, the CPOE system at the Brigham and Women’s Hospital in Boston automatically searches for the most recent measure of kidney function for drugs that are dependent on renal elimination, and it prompts the physician to
order one if it is not present (Bates et al. 1998).
It identifies allergies and drug interactions. CPOE systems store allergies and screen for adverse drug interactions. These systems need to be calibrated to warn users of more serious interactions, because if they alarm too frequently over issues seen as insignificant, then the warnings are more likely to be ignored.
Bar Coding
Bar coding can be used in medicine to help identify patients and ensure that the correct medication or test is being administered to the correct patient.
Bar coding has several advantages in identifying patients. It can not only match the correct medication with the correct patient, but it can also eliminate reliance on verbal identification and avoid misinterpretation in situations involving language differences and communication barriers, such as hearing difficulties and literacy issues.
Automated Dispensing Machines with Medication Profiles
Automated dispensing machines can be effective in decreasing turnaround time, limiting access to medications, and, when combined with bar-code technology, decreasing errors and their harmful results. Access to medication is limited to only those medications that are present in the pharmacy profile, that is, medication orders that have been reviewed by pharmacists and added to the patient’s electronic profile. Nurses are able to override the system in specific circumstances when patient care may be compromised by a delay.
Smart Pumps
New pump technology, which is referred to as “smart pumps,” not only offers safeguards to prevent IV solutions from flowing into a patient without control but also contains a formulary database that alerts nurses when the flow rate selected will result in a dose that could harm the patient.
For more Information:
* Healthcare Management, Healthcare Strategy, Lean Healthcare, Healthcare Management Books. Safe and Reliable Healthcare. *
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