Patient Safety and Technology

Elizabeth A. Henneman, RN, PhD, CCNS Case Study

n 86-year-old female patient was admitted to the intensive care unit from the emergency department after an automobile accident in which she suffered bilateral pneumothoraces but had no other obvious injuries. She appeared very uncomfortable, writhing in bed and crying, but was not following commands or making eye contact. She was pulling on her restraints and appeared to be reaching out to touch the nurses hands. The family was out of the country and could not be reached for several days. The staff were becoming concerned that the patient was withdrawn or had another serious neurologic or psychologic illness. When the family members arrived, they were shocked to see their mother so distraught and quickly reached out to her and held her hand, which seemed to comfort her immensely. The staff expressed their concerns to the family about the patients lack of responsiveness. The family members explained that their mother was legally blind and completely deaf without her hearing aids. The family felt confident that her hearing aids and eyeglasses would be with her belongings. And sure enough, the hearing aids and eyeglasses were found in the patient belongings bag in the bedside table. After applying the hearing aids and eyeglasses, the patient was awake, alert, following commands, and smiling at her family and the nursing staff. Technology in the acute and critical care setting is typically equated with devices such as bedside monitors, computerized provider order entry (CPOE), bar-coding devices, mechanical ventilators, dialysis machines, point-of-care testing, ventricular assist devices, and computerized information systems. Yet, these are not the only technologies used to care for our acute and critically ill patients and keep them safe. Many less sophisticated technologies such as hearing aids and eyeglasses, which have been widely available for many years, play a key role in patient safety. Imagine the potential risks to the patient in this case study if no one had been available to alert the staff to this patients hearing and vision needs. The patient almost certainly would have suffered pain or been unable to alert the staff if she was feeling anxious or short of breath.

What Is Patient Safety Technology?

Patient safety is defined by the Institute of Medicine (IOM) as the prevention of harm caused by errors of commission and omission.1 Errors of commission are the types of error most commonly referred to; for example, the wrong dose of medication is given or a medication is administered at the wrong time. Errors of omission are less commonly reported or referenced; they are the errors that occur when a necessary therapy is not carried out. The failure to provide the patient in this case study with her hearing aids or eyeglasses would be considered an error of omission. It is also important to point out that patient safety includes not only physiologic safety but also psychological safety.

CE

Continuing Education

This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Define patient safety as described by the Institute of Medicine 2. Distinguish between errors of commission and omission 3. Identify at least 3 goals suggested by the Institute of Medicine for excellence in health care

Elizabeth A. Henneman is Associate Professor, School of Nursing, University of Massachusetts Amherst, 651 N Pleasant St, Amherst, MA 01003 (Bethann953@aol.com).

Reprinted from AACN Advanced Critical Care, Volume 20, Number 2, pages 128-132.

8 CriticalCareNurse / SUPPLEMENT, FEBRUARY 2010

Career Options 2010

Technology is defined as the science of practical or industrial arts or applied science.2 In health care, this would refer to the practical and applied methods that facilitate the delivery of care for patients, families, and patients. The IOM suggests that quality health care must be safe, patient-centered, timely, efficient, effective, and equitable.3 These goals for excellence in health care help guide the use and development of technology in the acute and critical care setting. Patient safety technologies can be broadly categorized into 4 categories: (1) those that support the direct hands-on care of the patient; (2) those that support documentation; (3) those that support meeting the needs of patients and families; and (4) those that support the staff caring for the patient and the family. Of course, exemplary technologies should be able to meet criteria within all of these categories. For example, a point-ofcare glucose monitoring system that would automatically test the blood glucose level from an existing arterial catheter, send the results electronically to the nurse, physician, and patient when appropriate, and automatically adjust the insulin administration according to an evidence-based protocol would be an example of a technology meeting all criteria within the 4 categories. It is common, however, for a technology that meets one criterion/goal to be in direct opposition to anther category. For example, CPOE systems and bar-coding technologies may be perceived by some clinicians as extra work that improves documentation but distracts from direct hands-on patient care. There seems little question that the aforementioned technologies offer the potential to improve patient safety. On the other hand, they require development, implementation, and reevaluation strategies that are challenging in the current, hectic, and resource-limited health care setting. The following is a discussion of some of the patient safety issues associated with the more commonly used technologies in the acute and critical care setting, including bedside monitoring, bar-coded medication administration (BCMA) systems, and CPOE.

viewed as a means of having patients receive more expert care. For example, intermediate care units have increased in numbers over the past 2 decades. Most of these units offer some type of cardiac or pulse oximetry monitoring capability. In addition, staffing ratios are typically higher on these units, thereby giving physicians an incentive to admit their patients to these units so that the patient is monitored more closely. The patient safety issue is that cardiac rhythm or oxygen saturation monitoring may not be the type of monitoring the patient requires and actually becomes a resource drain on the staff and a distraction to providing appropriate care. In addition, the use of any kind of physiologic monitoring requires that the staff caring for the patient know how to use and apply the information provided by these monitors. With the current shortage of clinicians, this is unfortunately not always the case, leading to a false sense of security that can contribute to patient safety issues.

Bar-Coded Medication Administration Systems

The goal of BCMA systems is to prevent medication administration errors. This is an important technology because medication administration errors account for 26% to 32% of adult patient medication errors.4 BCMA systems are useful for matching the information on a patients armband with the ordered drug, dose, route, and time. They do not ensure that the armband is on the correct patient or that the drug or drug dosage ordered for the patient is appropriate for that patient at that particular time. This patient safety process still falls to the nurse who ultimately administers the medication. For example, the information on the patients armband may match the order for the appropriate -blocker. However, the nurse must still be aware of the indications for holding the -blocker (eg, low heart rate). Current BCMA systems do not alert the nurse to patient-specific situations in which it is not appropriate to administer a medication. This remains a nursing judgment. Thus, valid concerns from a patient safety perspective arise because BCMA systems may lead to less nursing vigilance in checking the appropriateness of the medication for a given patient at a given time. More sophisticated BCMA systems designed to integrate appropriate physiologic data with medication orders could improve this aspect of BCMA. The issue of verifying patient identification becomes crucial with BCMA systems. The verification process is one in which the patient (or the family member if the patient in unable to perform the task) is asked to state his or her name and date of birth and the information is compared with the information on the armband. Armbands are most commonly placed by registration clerks or technicians who may or may not have been trained in the correct process for verifying patient identification. Finally, a number of work-arounds have been reported with the use of BCMA systems.5 These work-arounds present serious threats to patient safety. They include affixing patient
CriticalCareNurse / SUPPLEMENT, FEBRUARY 2010 9

Bedside Monitoring
Bedside monitoring of cardiac rhythm, blood pressure, hemodynamics, oxygenation, and intracranial pressure has long been available for patients in the acute and critical care setting. These types of physiologic monitors provide alerts to changes in the patients condition to facilitate rapid and appropriate intervention. Nonetheless, it is now evident that there are limitations to the use of many monitoring technologies. The complexity of patient conditions in acute and critical care units demands a surveillance process that depends highly on the ability of the clinicians caring for the patient to integrate information obtained from bedside monitors with alert systems and patient data obtained from other sources. One patient safety concern related to bedside monitoring is that the use of cardiac or other monitoring devices may be

Career Options 2010

identification bar codes to computer carts or door jams and carrying several patients prescanned medications on carts. In addition, problems with the BCMA systems have been identified, including unreadable medication bar codes, nonbar-coded medications, malfunctioning scanners, and missing patient identification armbands.5 Particularly pertinent to work- arounds in the acute and critical care setting are emergency situations in which time is of the essence in administering medications, and bar code scanning potentially slows the administration process.

outcomes can be achieved by increased involvement of the family in the communication process, but this is an area that warrants further study. Communication boards such as dry erase boards have also been used as a technology to improve team communication. This type of board serves a dual purpose as a communication system for both staff and patients and families.11

Education
New technologies are also available to assist in the education of students and nurses in the academic and clinical setting. One of these technologies involves human patient simulation mannequins that are designed to mimic many of the normal physiologic patterns, such as breathing, heart rate, and blood pressure. One of the most important aspects of the use of human patient simulators is that they facilitate the opportunity for students and clinicians to practice assessment and intervention skills in a safe environment that does not place patients at risk of harm. A growing body of literature exists regarding the use of human patient simulation in health care, suggesting that this technology offers great potential benefits in improving patient safety.12-16

Computerized Provider Order Entry

CPOE has long been touted as a technology that could transform medication safety. The safety opportunities that can be afforded by CPOE include the legibility of provider orders and the use of standardized order sets. Despite this potential for safety, by 2002, only about 10% of hospitals in the United States had fully adopted CPOE.6 CPOE systems do not always improve patient outcomes, such as adverse drug events. In one study of pediatric patients, the implementation of CPOE was associated with an increase in medication errors.7 Although it is not entirely clear how CPOE negatively impacts outcomes, there is the potential for changes in workflow, such as a decrease in face-to-face communication and a potential decrease in collaborative care planning when CPOE is utilized. The use of standard order sets, although not unique to CPOE, has the potential to create a plan of care that may not be entirely appropriate for a specific patient, thus creating additional patient safety issues. The process of verification of orders that are entered into the patient record is also a safety issue when using CPOE. A recent study reported that health care providers fail to verify patient identity when ordering tests using a CPOE system.8

Future Directions
Two imperatives exist for the use of patient safety technology. One is to use existing technology to its fullest potential, an area in which we clearly need improvement. The other is to place a priority on the creation of new technologies that meet the IOM criteria of being safe, patient-centered, efficient, and effective. However, there are many challenges to the development and testing of new technologies in a resourcerestricted environment. It is also essential that health care professionals collaborate with colleagues in diverse fields such as engineering, computer science, and business if we are to truly develop patient safety technologies that will transform health care.17 One area of greatest need involves creating additional technologies to support the nurse at the bedside in performing surveillance and clinical decision making. It has been suggested that it is not humanly possible to collect and interpret all of the information needed to provide care to patients.17,18 Acute and critical care nurses need clinical decision support systems that enhance their ability to perform surveillance efficiently and effectively. Surveillance is a systematic, goaldirected process that focuses on the early identification of potential and actual adverse events, complications, and medical errors. Surveillance includes both data collection and data analysis.19 The early recognition of complications such as sepsis is necessary for timely treatment to be initiated.20,21 Most of the technologies used in the acute and critical care setting rely on human recognition for the interruption of adverse events. Clinical decision support systems are an example of a technology that has great potential to support all clinicians in the surveillance process and reduce the burden

Underutilized Technologies
As illustrated in this case study, basic technologies available to health care providers are underutilized, many of which are related to communication. This is important because communication errors account for most medical errors.9 Although many of the communication errors discussed in the literature focus on provider-to-provider communication, there are also serious failures in provider-to-patient/family communication that can lead to error. The use of communication tools, typically in very rudimentary forms (eg, pencil and paper), has long been in place to help health care providers determine the concerns and needs of our patients. This is an area in which much technologic progress has been made, although it is unclear how much of this technology is actually being used. Evidence suggests that the use of communication boards improves communication and decreases patient stress.10 One of the largest hurdles to the use of these boards is having the clinician resources available to spend the necessary time with the patient who is using these tools. It is possible that improved

10 CriticalCareNurse / SUPPLEMENT, FEBRUARY 2010

Career Options 2010

placed on the bedside nurse to collect and analyze an overwhelming amount of information.22,23

Conclusion
Many patient safety technologies are already widely available. Like any technology, they are effective only if they are used and they are only as good as the people who use them. The first step in meeting the IOM criteria for improving health care is having care that is safe and patient-centered at the most basic levels. In the case study presented, a safe, patient-centered approach may have resulted in the staff attending to the potential hearing and vision needs of an 86-year-old woman. A quick glance into the patients bag of belongings may have revealed her hearing aid and eyeglasses. What probably happened was that the well-meaning staff members were distracted by the many other tasks and technologic imperatives involved in the patients care and may have been so overwhelmed that they lost sight of the patients communication needs. More sophisticated and new technologies require that time and effort be taken to ensure that staff members are aware that the technologies exist, both to know when and whether they are indicated and to understand how they can be used for maximum effectiveness. This takes a level of resource support that is not always available. Consideration of available resources must be acknowledged by those in leadership positions if any technology is to be used safely.
References
1. Institute of Medicine. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004. 2. Websters New World Dictionary. Cleveland, OH: Pocket Books; 1995. 3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 4. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34. 5. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes and threats to patient safety. JAMA. 2008;15:408-423. 6. Gross PA, Bates DW. A pragmatic approach to implementing best practice for clinical decision support systems in computerized provider order entry systems. J Am Med Inf Assoc. 2007;14:25-28. 7. Walsh KE, Adams WG, Bauchner H, et al. Medication errors related to computer provider order entry. Am J Med Inf Assoc. 2007;14:415-423. 8. Henneman PL, Fisher DL, Henneman EA, et al. Providers do not verify patient identification during computer order entry. Acad Emerg Med. 2008;15:641-648. 9. The Joint Commission. Root causes of all sentinel events. http://www .jointcommission.org/Medication-Safety-Articles. Accessed May 3, 2007. 10. Patak L, Gawlinski A, Fung NI, Doering L, Berg J, Henneman EA. Communication boards in critical care: patients views. Appl Nurs Res. 2006;19:182-190. 11. Henneman EA, Dracup K, Ganz T, Molayeme O, Cooper CB. Using a collaborative weaning plan to decrease duration of mechanical ventilation and length of stay in the intensive care unit for patients receiving long-term ventilation. Am J Crit Care. 2002;11:132-140. 12. Henneman EA, Cunningham H, Roache JP, Curnin ME. Human patient simulation: teaching students to provide safe care. Nurse Educ. 2007;32:212-217. 13. Henneman EA, Cunningham H. Using clinical simulation to teach patient safety in an acute/critical care nursing course. Nurse Educ. 2005;30:172-177.

14. Seybert AL, Laughline KK, Barton CM, Rea RS. Pharmacy student response to patient-simulation mannequins to teach performance-based pharmacotherapeutics. Am J Pharm Educ. 2006;70:48. 15. Wallin CJ, Meurling L, Hedegard J, Fellander-Tsai L. Target focused medical emergency team training using a human patient simulator: effects on behavior and attitude. Med Educ. 2007;41:173-180. 16. Weller JM. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ. 2004;38:32-38. 17. Institute of Medicine. Building a Better Delivery System: A New Engineering/Healthcare Partnership. Washington, DC: National Academies Press; 2005. 18. Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002;8:316-320. 19. Surveillance: safety. In: Bulechek GM, Butcher HK, Dochterman JM, eds. Nursing Interventions Classification (NIC). 5th ed. St Louis, MO: Mosby; 2008:704. 20. Giuliano KK. Physiological monitoring for critically ill patients: testing a predictive model for the early detection of sepsis. Am J Crit Care. 2007;16:122-131. 21. Dellinger R, Carlet J, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32:858-872. 22. Sucher JF, Moore FA, Todd SR, Sailors RM, McKinley BA. Computerized clinical decision support: a technology to implement and validate evidence-based guidelines. J Trauma. 2008;64:520-537. 23. Weber S. Clinical decision support systems and how critical care clinicians use them. J Healthc Inf Manag. 2007;21:41-52.

Career Options 2010

CriticalCareNurse / SUPPLEMENT, FEBRUARY 2010 11

Test ID CG02102: Patient Safety and Technology Learning objectives: 1. Define patient safety as described by the Institute of Medicine 2. Distinguish between errors of commission and omission 3. Identify at least 3 goals suggested by the Institute of Medine for excellence in health care

CE Test

1. According to the Institute of Medicine, which of the following is the definition of patient safety? a. An environment without errors to patients or family members b. Absence of any type of medication errors involving patients c. Proper patient identification completed for tests and medication administration d. Prevention of harm to patients caused by errors of commission and omission 2. Failure to provide a patient with his/her hearing aids or glasses is which of the following? a. Obstruction of health care needs b. An error of omission c. Obstruction to patient communication d. An error of commission 3. According to IOM goals, quality health care should be which of the following? a. Patient-centered, cost-effective, equitable b. Timely, cost-effective, safe c. Effective, timely, regulated d. Patient-centered, safe, effective 4. The patient safety issue related to physicians admitting more patients to intermediate care units because of better staffing ratios includes which of the following? a. A distraction to appropriate care because patients may not need cardiac rhythm or oxygen saturation monitoring b. An unnecessary and increased expense patients cant afford and insurance will not reimburse for c. Patients from intensive care are unable to transfer resulting in increased length of stay d. Patients are discharged from intensive care units with inadequate discharge teaching 5. Medication administration errors account for which of the following? a. 28% to 32% of all patient medication errors b. 26% to 32% of all adult patient medication errors c. 28% to 32% of all adult patient medication errors d. 26 to 32% of all patient medication errors
1. K a Kb Kc Kd 2. K a Kb Kc Kd 3. K a Kb Kc Kd 4. K a Kb Kc Kd 5. K a Kb Kc Kd 6. K a Kb Kc Kd

6. Which of the following is a patient safety concern when using a barcoded medication administration (BCMA) system? a. The patient does not receive all of the scanned medications b. Override allows medications not ordered to be given c. Nurses have less vigilance in checking the appropriateness of medications d. The scanning device causes harm to patients skin with frequent use 7. Which of the following work-arounds with the use of the BCMA system poses a serious threat to patient safety? a. Checking the medication with a second nurse instead of scanning the bar code b. Charting medications after they are administered c. Armbands attached to door jams d. Manual charting of medications 8. Which of the following type of errors accounts for most medical errors? a. Communication b. Documentation c. Medication d. Omission 9. Which of the following technologies in education offers great potential in improving patient safety? a. Handheld personal digital assistants b. Dry erase boards c. Human patient simulators d. Text books on DVD 10. Which of the following do most of the technologies used in acute and critical care settings rely on for the interruption of adverse events? a. Clinical decision support systems b. Human recognition c. Physician interpretation d. Multiple monitoring systems 11. Which of the following is the first step in meeting IOM criteria for improving health care? a. Adding clinical decision support systems b. Using human patient simulators c. Practicing safe and patient-centered care at basic levels d. Using BCMA systems
7. K a Kb Kc Kd 8. K a Kb Kc Kd 9. K a Kb Kc Kd 10. K a Kb Kc Kd 11. K a Kb Kc Kd

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

Test ID: CG02102 Form expires: February 1, 2012 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 8 correct (73%) Category: Synergy CERP C

Test writer: Brenda Hardin-Wike, RN, CNS, MSN, CCNS

Program evaluation
For faster processing, take this CE test online at www.ccnonline.org (CE Articles in this issue) or mail this entire page to: AACN, 101 Columbia Aliso Viejo, CA 92656.
Objective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my nursing practice K My expectations were met K This method of CE is effective for this content K The level of difficulty of this test was: K easy K medium K difficult To complete this program, it took me hours/minutes. Yes K K K No K K K K K K

Name Address City Country E-mail RN Lic. 1/St Payment by: Card # Signature K Visa K M/C RN Lic. 2/St K AMEX Phone

Member #

State

ZIP

K Discover

K Check Expiration Date

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

12 CriticalCareNurse / SUPPLEMENT, FEBRUARY 2010

Career Options 2010