Marta L. Render

Examining the complexity behind a medication error: generic patterns in communication

Communication was the most frequently cited cause of medication errors reported between 1995 and 2003. More detailed models of how communication breakdowns contribute to adverse events are needed to intervene to improve communication processes. We describe in detail an incident where an oncology fellow physician erroneously substituted the medication navelbine for the intended etoposide during ordering, resulting in a prolonged hospitalization with severe leukopenia for the patient. A team of human factors and medical experts analyzed the case and identified communication patterns described in the human factors literature. We discuss how the findings suggest targeted ideas for improving communication processes, media, and systems that may have higher traction for improving patient safety than are possible solely from aggregated analyses of coded descriptions of large sets of cases.

Handoffs During Nursing Shift Changes in Acute Care

Handoffs during the nursing shift change were directly observed on two acute care wards each of a private and public hospital, for a total of 236 patient updates by 49 nurses during 14 shift changes. Data from the three wards which conducted audio-taped updates were transcribed. The transcriptions and field notes were analyzed for the existence and frequency of 21 strategies used in high reliability organizations. In addition, we iteratively categorized the interruptions, questions, and statements made during the updates. Finally, we iteratively categorized stances towards decisions communicated during the updates. Implications of the findings are discussed.

Repeating Human Performance Themes in Five Health Care Adverse Events

Public dread following well-publicized accidents energized the desire to learn from adverse events in health care. This paper summarizes an attempt to partner medical and human factors expertise to identify repeating human performance themes across adverse events. An interdisciplinary team interviewed 30 health care personnel from multiple facilities about five complex medical incidents. Ninety human performance themes were examined for each incident. Of these, ten human performance themes were identified to be salient in at least three of the incidents. Although none of these themes directly point to solutions, they increase our understanding of recurring themes across medical cases and can point to similar themes, and how they have been addressed, in other high-consequence, complex, socio-technical domains, such as aviation.

Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis:

In this paper, we explore the barriers wrong-site surgery guidelines face when applied in current work practice. Over 40 hours of direct observation of the entire care process (from initial consultation through post-operative care) were conducted. A breakdown in communication between surgical team members and the patient, operating room policy and procedures, incomplete patient assessment, staffing issues, distraction, and availability of pertinent information were identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1998. In response to the high visibility of wrong-sited surgeries, the American Academy of Orthopedic Surgeons (AAOS) among others, developed guidelines intended to reduce the risk but failed to account for the dynamic complex environment. Several process elements emerged from our analysis of observation and interview data as they affected the outpatient surgical process of identification. This paper suggests strategies to enhance resiliency already present in the system.

New Arctic Air Crash Aftermath Role-Play Simulation™: Orchestrating a Fundamental Surprise

We describe an aviation scenario-based role-play simulation used to teach healthcare practitioners about barriers to learning from accidents. Participants searched for the causes of the crash in a scenario that encouraged a “garden path” explanation that the root cause was a risky decision to take off despite visible ice on the wings. During a debriefing session, the actual structure of how the system failed is revealed, including over 100 active and latent contributors to the failure with a multitude of potential lessons to improve safety. The dissonance between lessons learned during the role-play and the potential lessons creates a “fundamental surprise” situation that allows oversimplified assumptions of how complex systems fail to be challenged.

Clinical Reminders: Explaining Variability in Adoption by Nurses and Physicians at Four Outpatient Clinics

Computerized clinical reminders (CRs) can improve compliance with evidence-based practices in preventive care and chronic disease management. However, observational research is needed to explain the known variability in the use of CRs. We conducted ethnographic observations of nurses and providers using CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers. We found that use of CRs was impeded by (1) lack of coordination between nurses and providers, (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions, (3) workload, (4) lack of CR flexibility, and (5) poor interface usability. We discuss implications of these findings for CR system design and provide recommendations for redesign to facilitate the effective use of CRs.

The Tradeoffs and Side-Effects of Migrating from Wireless Computer to PDA-Based Support for Medication Administration

This research involved evaluating a PDA application developed to provide a more mobile version of an existing Veterans Administration software program called BCMA (Bar Code Medication Administration). The original application was designed to be operable from a wireless desktop or laptop computer situated on a cart and connected with a bar code scanner to scan patient wristbands and medication labels. The primary goals of this system are to verify the medications about to be given to a particular patient are those ordered and to document the process. The PDA version is intended to meet the same goals utilizing a scanner built into the PDA itself, but also offer the benefits of a small, light-weight, mobile system. The evaluation involved usability inspection, usability testing, and structured interviews. The results describe (1) how the operating systems virtual keyboard display interacted with critical data in the application; (2) how the application software developers dealt with the challenge of a small screen size and the implications of those decisions; and (3) how users adapted their workflow attempting to maximize the benefits of greater mobility, while compensating for a loss in visibility.

Creating Patient Safety with Organizational Learning: A Case-Based Learning Intervention at a Public and Private Hospital

A critical component of a high reliability organization (HRO) is believed to be a safety culture. Historically, healthcare placed the onus on individuals for perfection in performance of complex work. A six-month, case-based learning intervention at a public and private hospital, Safety Minutes™, attempted to shift the focus from the individual to systems. The intervention is organized in rotating modules of a medical and non-medical incident that exemplify a safety concept, displayed via posters in a staff meeting space, followed by a moderated discussion. Moderators asked how the stories resembled or differed from the nurses experiences and guided participants away from ingrained “blame” responses in order to look more deeply at systemic and organizational factors. We assessed program effectiveness by ethnographic analysis of written transcripts of the moderated sessions and discuss lessons learned.

Towards a Functional Model of Quality Improvement Collaboratives

Quality improvement collaboratives (QIC) are widely used for seeking improvements in healthcare quality and safety. Nevertheless, the effectiveness of QICs is variable. In order to support research that identifies critical elements in running a successful collaborative, we fill a conceptual gap by moving towards a functional model of QICs. Specifically, we define how QICs are distinct from traditional quality improvement teams, conceptualize how primary and secondary functions are accomplished in a means-ends framework, and illustrate how the functions are dynamically accomplished in a series of meetings by nested teams within a collaborative. Finally, we discuss distinctions among QICs.

Differences in the Use of Bar Code Medication Administration (BCMA) in Acute Care and Long-Term Care Settings

In this paper, we explore how the use of a software package, Bar Code Medication Administration (BCMA), differs in acute care and long-term care settings. Direct observation of BCMA use during medication administration was conducted on acute care (42 hours) and long-term care (37 hours) wards in a small, medium, and large hospital. The following differences were found for all three hospitals: 1) acute care ward nurses used more detailed printed reports to plan medication passes and detect errors in ordering and dispensing than on the long-term care wards, 2) barcoded wristbands were scanned more frequently to identify patients on acute care than long-term care wards (53% vs. 8%), and 3) nurses administered medications immediately after scanning and opening medication packets more frequently on acute care than long-term care wards (93% vs. 23%). The findings highlight the need to tailor the BCMA software for the long-term care setting in order to improve patient safety.