The Quality - Cost Connection: Share automation-enabled error stories with staff
January 1, 2007 4 minutes read
Share automation-enabled error stories with staff
Task management to become increasingly important
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
In a perfect world the people who care for patients would never make a mistake and the operations of a health care facility would be under complete control at all times. There would be no unplanned, undesirable events, and no accidents, incidents, or inefficiencies. Unfortunately, such perfect control does not exist. Every human action taken in the provision of health care services is an opportunity for error. An action may be a visible act, such as raising the patient's bedrails; an internal process, such as reading the patient's health record; or even a lack of activity, such as omitting the procedural step of checking the patient's allergy history.
A common patient safety improvement strategy is automation. Automation refers to a wide range of technological advances that are used by health care professionals during the provision of patient services. Automation can be divided into two classes: perceptual devices and controlling devices. Perceptual devices help practitioners better understand the environment. For example, an automated telemetry device that emits a signal when a patient's heart rhythm is erratic helps people know that the patient is in need of immediate assistance. The telemetry device does not control the patient's heart rhythm. Another general type of automation is used for controlling purposes. This type of automation contrasts with the perceptual device because it enhances the practitioner's ability to diagnose or treat the patient, rather than merely perceive the patient's current state. An example of a controlling device is a computerized order entry that prevents the practitioner from ordering a medication to which the patient has an allergy. Implantable pacemakers are automated devices that actually control a patient's heart rhythm. Automation includes, but is not limited to: electronic records, electronic communication, electronic patient monitoring equipment, electronic medication dispensing devices, computerized decision support systems, physician order entry, web-based applications, and hand-held wireless devices.
Compared with other industries, health care has been slow to embrace new technologies. This has resulted in avoidable errors and, in some instances, significant patient harm. Public sentiment and external forces such as the Leapfrog Group have become a catalyst for adoption of automated solutions to patient safety problems. It's true that automating patient care tasks can potentially diminish common slips or mistakes. However, automation itself introduces a different class of hazards into the health care workplace. Health care professionals must understand the risks of automation-enabled errors so that significant problems can be avoided.
The addition of automated devices may create the opportunity for errors that had not been possible in the past or increase the chance of previously existing errors to occur. The use of automation may make task management more difficult for caregivers, possibly leading to unsafe conditions. Task management refers to the process by which a human manages his or her available sensory and mental resources in a dynamic, complex, safety critical environment in order to accomplish multiple tasks that are competing for his or her limited quantity of attention. Many health care practitioners work in highly complex or rapidly changing environments (e.g. intensive care unit, emergency department, operating room, emergency medical services, etc.). In these environments people must prioritize tasks because they do not possess the necessary resources to simultaneously execute all the tasks that demand their attention. Introduction of automation into these environments can create new opportunities for errors. Automated systems can:
- Increase demands on users' memory.
- Cause users to be uncertain as to where and when they should focus their attention.
- Make it difficult for users working in teams to share the same situational awareness.
- Impair mental models of the system.
- Increase workload during high-demand periods.
- Limit the users' ability to develop effective strategies for coping with task demands.
- Increase stress and anxiety.
- Increase the potential for confusion.
Even when automation works as intended, the systems that support the automated processes can fail. Some hospitals have invested in electronic bar coding systems for medication administration. All patient medications are labeled with the patient's unique bar code identification (ID).
No medication is supposed to be given until the patient's ID is scanned with a portable scanner and found to match the bar code on the medication. If there is not a match, medication administration is delayed until the problem is resolved.
This sounds like a fairly foolproof system; however, there are numerous anecdotes of how caregivers are using "workarounds" or short-cuts that over-ride the safety aspects of these systems. Despite technological advances, preventing mistakes will always depend on the vigilance and safe practices of individuals. Human carelessness or noncompliance with safeguards can render useless the very systems designed to avert mistakes.
Automation presents no clear detriment to patient safety. However, with the addition of any new technology comes the potential for new types of human errors and system failures. For instance, an error during patient registration might be perpetuated throughout the hospitalization by the information systems and be more difficult to correct than with paper-based systems. The safety problems that are introduced by new technologies are not insurmountable.
It is important that quality managers gather information about automation-induced errors and share that information with caregivers. Use storytelling, based on incidents that have occurred in your facility, to constantly remind staff of the safety hazards of automated patient care devices. By learning about these errors, staff will soon discover that automation can create new mishaps that are potentially more serious than those we are seeking to avoid. Vigilance and continued analysis of the cause of errors is important.
In a perfect world the people who care for patients would never make a mistake and the operations of a health care facility would be under complete control at all times. There would be no unplanned, undesirable events, and no accidents, incidents, or inefficiencies.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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