Post on 06-May-2017
transcript
The Culture of HealthcareSociotechnical Aspects:
Clinicians and Technology
This material (Comp2_Unit10a) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number
IU24OC000015.
Lecture a
Sociotechnical Aspects: Clinicians and Technology
Objectives – Lecture a• Describe the concepts of medical error and patient safety (Lecture
a, b)• Discuss error as an individual 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 (Lecture a, b)
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Lecture a
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
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Medical Errors• In 1964, one study 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 U.S., medical errors are estimated to
result in 44,000 to 98,000 unnecessary inpatient deaths annually
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Adverse Events• Adverse events occur in all healthcare systems
and in all nations• Data suggests a majority of these events occur
in the hospital setting• Other areas not immune to adverse events
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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 healthcare workers may have
insufficient technical skills due to inadequacy of training
– Operating costs are often underfinanced
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Types Of Errors• Errors Caused By Individuals:
– Unintended acts of omission or commission– Acts that do not achieve their intended
outcomes • Errors Caused By Systems:
– Complexity of healthcare and healthcare technology
– Complexity of disease and dependence on intricate clinical collaborations and interventions
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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
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Lecture a
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
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Slips – Solving The Problem
• Need to limit opportunities for loss of attention• Example: sleep deprivation during resident
training• Resident training in the US – limit to the number
of duty hours per week to reduce slips due to fatigue and sleep deprivation
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Lecture a
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 solution
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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
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System Errors
• System errors: these errors occur because of inadequacies within the system
• Often committed by multiple individuals who intersect with patient care
• Often difficult to analyze
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Lecture a
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 1 unintended medication discrepancy at hospital admission
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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
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Medication Reconciliation• Methods for medication reconciliation:
– Only pharmacists order medications– Linking process to computerized physician
order entry (CPOE)– Integrating medication reconciliation in the
EHR– Patients reconcile their medications instead of
clinicians• Studies suggest reduction in errors but have not
yet demonstrated improvement in outcomes16Health IT Workforce Curriculum
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Who is Driving Patient Safety Initiatives?
• Clinicians • Hospitals• Regulatory bodies – for example, the Joint
Commission on Accreditation of Healthcare Organizations
• Patients
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Lecture a
Sociotechnical Aspects: Clinicians and Technology
Summary– Lecture a
• Focused on medical errors and patient safety• Distinguished slips from mistakes• The concept of system errors • Examined the driving forces championing patient
safety initiatives.
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Lecture a
Sociotechnical Aspects: Clinicians and Technology
References – Lecture aReferences• Auerbach, A., Landefeld, C., et al. (2007). The tension between needing to improve care and knowing how to do it.
New England Journal of Medicine, 357: 608-613.• Donabedian, A. (1988). The quality of care: how can it be assessed? Journal of the American Medical Association,
260: 1743-1748.• Kohn, L., Corrigan, J., et al., eds. (2000). To Err Is Human: Building a Safer Health System. Washington, DC.
National Academies Press.• Krumholz, H. and 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. Journal of the American Medical
Association, 284: 95-97.• McGlynn, E., Asch, S., et al. (2003). The quality of Healthcare delivered to adults in the United States. New
England Journal of Medicine, 348: 2635-2645.• Nolte, E. and McKee, C. (2008). Measuring the health of nations: updating an earlier analysis. Health Affairs, 27:
58-71.• Schimmel EM. The Hazards of Hospitalization. Ann Intern Med January 1, 1964 60:100-110• Sox, H. and Woloshin, S. (2000). How many deaths are due to medical error? Getting the number right. Effective
Clinical Practice, 6: 277-283.• The State of Healthcare Quality: 2009. Washington, DC, National Committee for Quality Assurance.
http://www.ncqa.org/tabid/836/Default.aspx.
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Lecture a