UNIVERSITY OF SAINT ANTHONY

(Dr. Santiago G. Ortega Memorial)

Iriga City

HEALTH CARE EDUCATION DEPARTMENT

CHAPTER 15: INFORMATICS TOOLS TO PROMOTE PATIENT SAFETY, QUALITY

OUTCOMES, AND INTERDISCIPLINARY COLLABORATION

Introduction
● Nursing professionals have an ethical duty to ensure patient safety.
● “Direct care nurses, at their core, are risk managers. They attach meaning to
what is and anticipate ‘what might be” (Lavin et al. 2015)
● Medical errors are the third-leading cause of death in the United States
(McMains, 2016)
● Increasing demands on professionals in complex and fast-paced healthcare
environments may lead them to cut corners or develop work-arounds that
deviate from accepted and expected practice protocols.

Sentinel Event
● A patient safety issue that results in death, permanent harm, or serious
temporary harm that requires intervention
● Any unanticipated event in a healthcare setting that results in death or serious
physical or psychological injury to a patient, not related to the natural course of
the patient's illness.

Smart Pump
● A programmable computerized drug infusion device that contains a drug library,
also known as a dose error-reduction system.
● Dose calculation software that compares that programmed infusion rate to a
drug database to check for dosing within safe limits.
● This technology is particularly important when high-alert or high-hazard drugs
are being administered.

What is a Culture of Safety?

● The 2000 Institute of Medicine’s report To Err Is Human is widely credited for
launching the current focus on patient safety in health care.
● Agency for Healthcare Research and Quality (AHRQ) launched initiatives focused
on safety research for patients.
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

● Other initiatives prompted by these seminal reports were the Joint Commission’s
National Patient Safety Goals (updated yearly since 2002).
● Adverse Events- any undesirable experience or outcome in a patient related to
the use of a medical treatment or product.
● Never Events- an occurrence that should never happen, such as wrong-site
surgeries and retained surgical objects.
● The AHRQ (2019) safety culture primer suggested that organizations should
strive to achieve high reliability by being committed to improving healthcare
quality and preventing medical errors and demonstrating an overall commitment
to patient safety.

Key Features of a Safety Culture (AHRQ)

● Acknowledge of the high-risk nature of an organization’s activities and the
determination to achieve consistently safe operations
● A blame-free environment where individuals are able to report errors or near
misses without fear of reprimand or punishment.
● Encouragement of collaboration across ranks and disciplines to seek solutions to
patient safety problem
● Organizational commitment of resources to address safety concerns

Patient Safety and Quality Improvement Act of 2005

➔ Mandated the creation of a national database of medical errors and funded
several organizations to analyze these data with the goal of developing shared
learning to prevent medical errors.
Root Cause Analysis
➔ Similar to failure modes and events analysis; analysis to discover why a process
is faulty or produces an undesired result.
Failure Modes and Effects Analysis (FMEA)
➔ A systematic evaluation of a process to determine how and why it failed to
produce the desired results.

Three Types Of Behaviors

● Human error (unintentional mistakes)
● Risky Behaviors (workarounds)
● Reckless behavior (total disregarded for established policies and procedures)
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

STRATEGIES FOR DEVELOPING A SAFETY CULTURE

● Strategies for achieving a safety culture have been addressed frequently in the
literature and embraced by several key organizations
● The focus here is limited to those strategies described by the three key
organizations:
 Agency for Healthcare Research and Quality (AHRQ)
 Joint Commission
 Institute of Healthcare Improvement (IHI)

Seven Steps for Action Planning (AHRQ)

1. Understand your survey results
2. Communicate and discuss survey results
3. Develop focused action plans
4. Communicate action plans and deliverables
5. Implement action plans
6. Track progress and evaluate impact
7. Share what works

Institute of Healthcare Improvement (IHI)

● Stressed that organizational leaders must drive the culture change by making a
visible commitment to safety and enabling staff to share safety information
openly.
● Released a white paper titled “A Framework for Safe, Reliable, and Effective
Care”, which emphasized the organizational culture, the need to establish a
learning system, and patient engagement as cornerstones of safety.

Joint Commission
● Emphasized the importance of leadership in a safety culture
● Leadership understands that systemic flaws exist and each step in a care process
has the potential for failure simply because humans make mistakes.
● Releases Hospital National Patient Safety Goals, The 2020 goals center around
patient identification, staff communications, medication use, alarms, infection
prevention, identifying patients at risk for suicide, and prevention of surgical
mistakes.
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(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

 JUST CULTURE: People are encouraged, even rewarded, for providing essential
safety-related information, but clear lines are drawn between human error and at
risk or reckless behaviors.
 REPORTING CULTURE: People report their errors and near misses.
 LEARNING CULTURE: People are willing and competent to draw the right
conclusions from safety information systems and willing to implement major
reforms when their need is indicated.

HUMAN FACTORS AND SYSTEMS ENGINEERING

 SYSTEMS ENGINEERING
➔ is the approach to patient safety, in which technology manufacturers partner
with organizations to identify risk to patient safety and promote safe technology
integration. (Ebben 2008 )
 HUMAN FACTORS ENGINEERING
➔ is the discipline of applying what is known about human capabilities and
limitations to the design of products, processes, systems, and work environments
 Ebben et al. also emphasized that testing human use factors provides more
objective safety data than the subjective responses gained from user preference
testing. “Understanding how the equipment shapes human performance is a
important as evaluating reliability or other technical criteria”

A World Health Organization (2016)

o publication makes an important point: “The overall human factors philosophy is

that the system should be designed to support the work of people, rather than
designing systems to which people must adapt”
o Further, this publication cautions that issues with information and information
chaos. It defined information chaos as follows:

 INFORMATION OVERLOAD
 INFORMATION UNDERLOAD
 INFORMATION SCATTER
 ERRONEOUS OR CONFLICTING INFORMATION
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(Dr. Santiago G. Ortega Memorial)
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HEALTH CARE EDUCATION DEPARTMENT

USER – TECHNOLOGY – PATIENT – SAFETY – SCHEME

 In 2016, the GOVERNMENT ACCOUNTABILITY OFFICE (GAO) selected and

assessed six hospitals, from which it identified three challenges in implementing
patient safety practices. The number one challenge was “obtaining data to
identify adverse reactions in their own hospitals”. Nursing informatics skills and
knowledge can address this challenge.
 The GAO interviewed patient safety experts and reviewed the related literature
to identify three key gaps where better information could help guide hospital
officials in their continued efforts to implement patient safety practices. These
gaps involve a lack of:
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

● Information about the effect of contextual factors on implementation of patient

safety practices
● Sufficiently detailed information on the experience of hospitals that have
previously used specific patient safety implementation strategies
● Valid and accurate measurement of how frequently certain adverse events occur.

INFORMATICS TECHNOLOGIES FOR PATIENT SAFETY

o Healthcare technologies are frequently designed to improve patient safety,

streamline, work process, and improve the quality and outcomes of healthcare
delivery. Although technology may certainly help to prevent or reduce errors, one
must remember that technology is not a substitute for safety vigilance by the
healthcare team in a safety culture.

o The Wired for Health Care Quality Act 2005 began a series of funding
streams to promote health IT and sharing of its best practices and help
organizations implement health IT.

o Medication errors are the most frequent and visible errors because the
medication administration cycle has many poorly designed work processes with
several opportunities for human error.

Computerized Provider Order Entry (CPOE) produces technologies that can help
healthcare providers to avoid medication error.
● Automated Dispensing Machine- were introduced in hospitals in the late
1980s. These decentralized medication-distribution systems provide computer-
controlled storage, dispensing, and tracking of drugs at the point of care in
patient-care units.
● Bar-Code medication Administration (BCMA)- Bar code medication
administration is a bar code system designed by Glenna Sue Kinnick to prevent
medication errors in healthcare settings and to improve the quality and safety of
medication administration.
● Smart pump- this technology is designed for safe administration of high-
hazard drugs and reducing adverse drug events during IV medication
administration.
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

● Clinical Decision Support (CDS)-A clinical decision support system is a health

information technology, provides clinicians, staff, patients, or other individuals
with knowledge and person-specific information, to help health and health care.

This designed to deliver:

 The right information ( evidence- based guidance to clinical need)

 To the right people (entire care team- including the patient)
 Through the right channels (e.g., HER, mobile device, patient portal)
 In the right intervention format (order sets, flow sheets, dashboard,
patient list)
 At the right points in workflow (for decision making or action)

Emergency Care Research Institute (ECRI)

➔ Was founded in 1968
➔ Designated by Health and Human Services (HHS) in 2008 as Patient Safety
Organization
➔ In 2020, it affiliated with the Institute for Safe Medication Practices and was
rebranded as ECRI “the most trusted voice in healthcare”.

Top 10 medical technology hazards identified by ECRI (2020)

1. Surgical staplers-staple line failures or misapplication
2. Point-of-care ultrasound-issues with user training, documentation and data
archiving
3. Infection risks from sterile processing-especially in medical and dental
offices and ambulatory settings.
4. Hemodialysis risks with central venous catheters in the home health
setting- risks include infection, clotting or hemorrhage.
5. Surgical robotic procedures-limited tactile feedback for forces exerted on tis-
sue may result in injury.
6. Alarm, alert, and notification overload-numerous alarms may cause a
clinically significant issue to be missed.
7. Cybersecurity risks in the home health setting-increased vulnerabilities
associated with remote monitoring and network connected medical technologies
8. Missing implant data for MRI scan patients-implants can hear, move or
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

malfunction when exposed to MRI's magnetic field.

9. Medication errors from dose timing discrepancies in electronic medical
records-discrepancies between dose timing intended by the provider and ours
ing workflow.
10. Loose nuts and bolts in medical devices-devices can tip, fall or collapse if
not properly maintained.

ADDITIONAL TECHNOLOGIES FOR PATIENT SAFETY

CDSs are designed to deliver the following:

● the right information (evidence- based guidance to clinical need)
● to the right people (entire care team- including the patient)
● through the right channels (e.g., HER, mobile device, patient portal
● in the right intervention formats (e.., order sets, flow sheets, dashboard, patient
list)
● at the right points in workflow (for decision making or action)

RFID TECHNOLOGIES
➔ contains a tag fixed to an object or a person that functions as a radio-frequency
transponder and provides a unique identification code, a reader that receives and
decodes the information contained on the tag, and an antenna that transmits the
information between tag and reader.

Usedto:
● track medical supplies and equipment
● Embedded in patient identification bracelets
● Used in the medication supply chain
● Embedded into surgical supplies
● Reduce the likelihood of the never events of wrong-patient, wrong site surgical
procedures
● Blood and blood products can be efficiently tracked

SMART ROOMS
➔ are also being used in healthcare facilities as a way to better engage patients
and families in the hospital experience.
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(Dr. Santiago G. Ortega Memorial)
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HEALTH CARE EDUCATION DEPARTMENT

Used to:
● Review patient data in real time and chart care at the bedside
● Workflow algorithms to alert clinicians as they enter the room about procedures
that need to be implemented for the patient
● Hospitals implementing an Internet of Things (IoT) device located at the bedside
SMART BEDS
➔ provide continuous rotation to prevent pressure ulcers, sense when a patient at
risk for a fall leaves the bed, and continuous monitor vital signs are also being
implemented
The Medical Futurist (2017) described several additional innovations includes:
● Robots to clean rooms
● Flat screen TVs run by mobile devices
● Record patient’s pain levels on mobile devices
● Project three-dimensional images in the room

WEARABLE TECHNOLOGY AND WIRELESS ARE networks called “body area

networks” or “patient area networks”
➔ ability to wear a small, unobtrusive monitor that collects and transmits
physiologic data via cellphone to a server for clinician review.

● Wireless chip on a disposable Band-Aid with a 5-7 day battery

➔ used to monitor the patient’s heart rate and electrocardiogram, blood
glucose, blood pH, and blood pressure

● Wearable stress-sensing monitors

➔ detect electrical changes in the skin

● CareGiver Smart Solutions, Forma SafeHome, LocateMotion SenSights,

StaySmartCare, Vayyyar Home and VitalCare Connect
➔ aid in home monitoring of an elder’s movement, sleep, fall detection,
health data and/or medication data

● Hospital gowns made with smart fabric

➔ provide vital signs monitoring or programmed to deliver medication via
the skin
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

ROBOTICS TECHNOLOGIES
● Surgical Robots
● Robotic exoskeleton
● Robobear
● Laser—guided robots
● Nanorobots

The International Medical Informatics Association (IMIA) Health Informatics for

Patient Safety Working Group enumerated 6 areas where health information system can
impact patient safety:
● Identifying and documenting how health information system and their associated
devices
● Identify and documenting software safety issues
● Discussing, developing, and promoting methodologies
● Educating health informatics professionals, health professionals, healthcare
administrators and policy makers
● Collecting, analyzing, and disseminating research results about health
information systems and medical devices

TECHNOLOGIES TO SUPPORT THE MEDICATION ADMINISTRATION CYCLE

o The steps in the medication administration cycle (ie, assessment of need,
ordering. dispensing, distribution, administration, and evaluation) have been
relatively stable for many years. Each of the steps depends on vigilant humans to
ensure patient safety, which resulted in the five rights of medication
administration:
(1) the right patient
(2) the right time and frequency of administration
(3) the right dose
(4) the right route
(5) the right drug.

 CPOE is an electronic prescribing system designed to support physicians and

nurse practitioners in writing complete and appropriate medication and care
orders for patients.
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

 In a stand-alone CPOE system without a CDS system, the medication

orders are simply checked by the computer against the drug database to ensure
that the dose and route specified in the order are appropriate for the medication
chosen. Specific benefits of a CPOE system include the following:

● Prompts that warn against the possibility of drug interaction, allergy, or overdose
● Accurate, current information that helps physicians keep up with new drugs as
they are introduced into the market
● Drug-specific information that eliminates confusion among drug names that look
and sound alike
● Reduced healthcare costs caused by improved efficiencies
● Improved communication among doctors, nurses, specialists, pharmacists, other
clinicians, and patients
● Improved clinical decision support at the point of care

 CPOE solves the safety issues associated with poor handwriting and
unclear or incomplete medication orders. Orders can be entered in seconds
and from remote sites, thereby eliminating the use of verbal orders, which are
especially subject to interpretation errors.

 The processes of drug storage, dispensing, controlling, and tracking are

easily carried out via automated dispensing cabinets (ADCs, also known
as automated dis- pensing machines, unit-based cabinets, automated
dispensing devices, and automated distribution cabinets). These devices
have benefits for both the user and the organiza- rion, specifically in the areas of
access security (especially with narcotics administration tracking), safety, supply
chain, and charge functions (Institute for Safe Medication Practices, 2019).

Applications (apps), or mobile apps, are being used by and prescribed for patients.
The apps used for patient education can engage and inform patients; an educated
patient is believed to be "more likely to understand risks and if there is an adverse
event, may be less likely to file a lawsuit" (Diamond, 2016, para. 2).

Radio-frequency identification (RFID) technology is rapidly gaining a foothold in

health care technology and may soon be used in the medication administration cycle.
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

Although more expensive than bar coding for packaging, the RFID tags are
reprogrammable, and issues associated with bar-code printing imperfections and
scanner resolution can be mitigated (Vecchione, 2015).

BCMA systems help to ensure adherence to the five rights of medication ad-
ministration. Whether BCMA is part of the larger EHR or a freestanding electronic
medication administration system (eMAR), bar-code technology provides a system of
checks and balances to ensure medication safety.

Smart pump technologies are designed for safe administration of high-hazard drugs
and reducing adverse drug events during IV medication administration. The IHI (n.d.c)
recommends the following steps to ensure safe implementation of smart pump
technology:
● Prior to deploying these pumps, standardize dosing units for a given drug (for
example, agreeing to always dose nitroglycerin in terms of mcg/min or
mcg/kg/min but not both).
● Prior to deploying these pumps, standardize drug nomenclature (for example,
agreeing to always use the term KCl, but not Potassium chloride, K, Pot Chloride,
or others).
● Perform a Failure Modes and Effects Analysis (FMEA) on the deployment of these
devices.
● Ensure that the concentrations, dose units, and nomenclature used in the pump
are consistent with that used on the Medication Administration Record (MAR) the
pharmacy computer system, and the electronic medical record.
● Meet with all relevant clinicians to come to agreement on the proper upper and
lower hard and soft dose limits.
● Monitor overrides of alerts to assess if the alerts have been properly configured
or if additional quality intervention is required.
● Be sure the "smart" feature is utilized in all parts of the hospital. If the pump is
set up volumetrically in the operating room but the "smart" feature is used in the
ICU, an error may occur if the pump is not properly reprogrammed.
● Be sure there are upper and lower dose limits for bolus doses, when applicable.
● Engage the services of a human factors engineer to identify new opportunities
for failure when the pumps are deployed.
● Identify a procedure for the staff to follow in the event a drug must be given
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(Dr. Santiago G. Ortega Memorial)
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HEALTH CARE EDUCATION DEPARTMENT

which is either not in the library or when its concentration is not standard.
● Deploy the pump in all areas of the hospital. If a different pump is used on one
floor and the patient is later transferred, this will create new opportunities for
failure. Also, there may be incorrect assumptions about the technology available
to a given floor or patient.
● Consider using "smart" technology for syringe pumps as well as large volume
infusion devices (para. 12).

Cummings and McGowan (2011) cautioned that nurses must never solely rely on
the pump to identify and alert them to problems. Nurses must always engage in best
practices and follow all patient safety practices. There is no substitute for nursing
assessment of patients as a key safety tool.

ROLE OF NURSE INFORMATICIST

NURSE INFORMATICIST
➔ provides information about new workflows, guides new technology and process
implementation, and assesses data quality, giving care teams the best chance of
optimal care delivery.
● Nurse informaticists and the IT team in the facility must ensure that all systems
are properly configured and maintained.
● They should routinely monitor and check these systems while making sure that
their users are capable of using the systems accurately to avoid errors.
● Nurse informaticists must be involved in all stages of the system development
life cycle as new technologies are introduced while maintaining a focus on safety.
● Nurse Informaticist can bridge the gap between IT staff, electronic systems
designed to ensure patient safety, and nurses who are system users by attending
to the disruptions inherent in technology implementation and promoting the best
and safest uses of the systems.
“Creating a safe patient environment is a very complex issue that will require the
combined knowledge and skill of clinical informaticists, informatics faculty, researchers,
and system designers” Effken and Carty (2002)

❖ The results of a 2020 Healthcare Information and Management

Systems Society (HIMSS) survey on the impact of nurse informaticists on
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

patient safety: demonstrates the belief that nurse informaticists can greatly
improve patient safety.
❖ In their conclusion, the researcher stated that: the role of informatics
nurses is not limited to IT; this research also suggests that informatics nurses
play an instrumental role with regard to patient safety, change management and
usability of systems as evidenced by their impact on quality outcomes, workflow,
and user acceptance.
● Nursing informaticists are “the driving force behind the development,
implementation, and optimization of electronic medical/health records, nursing
documentation, point-of-care clinical decision support, and computerized
practitioner order entry”

INTERDISCIPLINARY COLLABORATION & INTERPROFESSIONAL

COLLABORATION

➔ are terms used to describe cooperative relationships among actively engaged

professionals where healthcare decision-making is shared to combine their
collective knowledge and skills to care for their patients.
● All the professionals are working toward the same goal: positive patient
outcomes.
● The following are stated by Kuziemsky and Reeves (2012):
❖ Informatics and interprofessional collaboration are two fields where there
is great potential for synergy. Importantly, information technology can
assist communication between professionals in both a synchronous
fashion (e.g. computer conferencing and web-based interactions) and an
asynchronous manner (e.g. email and Wikis).
● Successful interprofessional collaborative education experiences will foster a
willingness to participate in interprofessional collaboration efforts on behalf of
patients.
● Informaticists must be willing to share, communicate, and deliberate with other
professionals caring for the same patient to achieve the best outcome for the
patient.

“Informatics is more than just technology. Rather it is an interdisciplinary science.”

- Kuziemsky and Reeves (2012)
 UNIVERSITY OF SAINT ANTHONY
(Dr. Santiago G. Ortega Memorial)
Iriga City

HEALTH CARE EDUCATION DEPARTMENT

SUMMARY

o This chapter explored the characteristics of a safety culture and technologies

designed to promote patient safety.
o The need to evaluate errors carefully to determine why and how they occurred
and how workflow processes might be changed to prevent future errors of the
same type was emphasized.
o The nurse informaticists, healthcare providers, patients, ancillary team members,
administrators, settings/ environments, infrastructures, and technologies must all
work together to create a safety culture.
o Every organization must provide safe, quality health care and prevent harm or
adverse events for every patient under its care by ensuring that patient safety is
critical to the organization’s mission.
o Organizations must make a commitment to a safety culture in which everyone at
every level is committed to patient safety at every moment. In an ideal world,
everyone would first stop and think “Is this safe?” Before every action,
workarounds would not occur, and everyone would embrace the technologies
and workflow processes designed to promote patient safety.

A list of websites to consult for updates on patient safety technologies

TITLE URL

AHRQ Patient Safety Network https://psnet.ahrq.gov

VA National Center for Patient Safety https://www.patientsafety.va.gov

Institute for Healthcare Improvement http://www.ihi.org/topics/patientsafety/

Pages/default.aspx

Center for Patient Safety https://www.centerforpatientsafety.org

QSEN Institute (Quality and Safety https://qsen.org

Education for Nurses)