Some unanticipated consequences of the implementation of a hospital IT system: learning from a case...
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Some unanticipated consequences of the implementation of a hospital IT system: learning from a case study Sabi Redwood Joel Minion Mary Dixon-Woods Anna
Some unanticipated consequences of the implementation of a
hospital IT system: learning from a case study Sabi Redwood Joel
Minion Mary Dixon-Woods Anna Rajakumar Ugochi Nwulu
Slide 2
Introduction Implementation of hospital IT systems to reduce
errors and improve practitioner performance As with any new
intervention, we need to be vigilant to unanticipated consequences
(both positive and negative) Short case presentations to stimulate
discussion about how organisations can detect and anticipate these
consequences.
Slide 3
Quality & Safety in the NHS Department of Health / NIHR
funded Includes up to 10 ethnographic case studies Focus on
innovative schemes to improve Q&S Observations/interviews at
sharp & blunt ends Computerised Prescribing System (CPS) IT
Systems as a Training Tool Case study of large urban teaching
hospital Focus on CPS developed in-house over 10 years Empirical
data collected through observations on wards, at CPS-related
management meetings, and in hospital pharmacy
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CPS tablets used routinely by pharmacists on wards to: review
patient medications and test results assess discharge summaries
prep patients for surgery (e.g. starting/stopping certain
medications) CPS also used to encourage pre-registration
pharmacists to think critically During rounds, typical
training-type questions included: Look at this drug chart and tell
me why the patient was admitted. Look for possible interactions in
this list. Tell me what you see. Explain why two opiates were
prescribed. Junior pharmacists were also encouraged to assess the
pharmaceutical implications of test results available through CPS
IT System as a Pharmacy Training Tool
Slide 8
Ready access to patient information drug chart dose
administration chart test results link to BNF Portability to move
easily within ward e.g. reviewing meds while checking bedside
lockers Need to think critically about limitations of in-built
clinical decision support Opportunity to review care plans more
broadly, looking for potential or real medical errors of other
health care professionals Enhanced Training Functionality of
CPS
Slide 9
Generating the risk of new errors in the medication prescribing
and administration process 15% of all medication related errors
were considered sociotechnical incidents. These incidents were
further divided into types of sociotechnical error. Missing
electronic signatures on administration (49%) Technical slips or
lapses during prescribing/administration (31%) Training related
(5.5%) Mixed economy related (11%) Prescribing privileges
(2.7%)
Slide 10
Issues raised by studying medication errors in a highly
computerised hospital: Creates auditable moments through heightened
visibility Potential instrument to monitor staff Mixed economy of
prescribing systems during roll out.
Slide 11
Why is it important to understand the sociotechnical nature of
medication errors? Clinical and technical implementers can design
out these unintended problems Training needs and weak spots can be
highlighted Clinical practice protocols can be revised and designed
to suit effective working practice.
Slide 12
Unintended consequences of computerised prescribing systems:
diminished professional expertise? WITH Mouse, MickeyHN000 Mouse,
MickeyHN000 Mouse, MickeyHN000 Mouse, MickeyHN000 Mouse,
MickeyHN000 Mouse, MickeyHN000 Mouse, MickeyHN000
Slide 13
Clinical Decision Support for e-prescribing: Uses technology to
impose guidelines Reduces the impact of differing clinical
competencies Individual clinical prescribing skills: Improved by
education and examinations Expertise gained through experience
Adaptive through clinical discretion Total safety = Safety imposed
+ Safety managed * Reduction in prescription errors Using
technology to increase patient safety at the hospital level ...does
this affect professional expertise at the clinician's level?
*Amalberti, R. Optimum system safety and optimum system resilience:
agonist or antagonists concepts? (2006)
Slide 14
Mouse, MickeyHN000 Mouse, MickeyHN000 Mouse, MickeyHN000 Mouse,
MickeyHN000 Mouse, MickeyHN000 Mouse, MickeyHN000 Mouse,
MickeyHN000 Junior Doctors Dashboard project Focus groups of junior
doctors will explore: 1.Their response to working with a
safety-focussed IT system 2.How they feel using the system affects
their competence to prescribe 3.Their views of working outside the
trust, without computerised prescribing systems designed for
patient safety.
Slide 15
The quality of paper is not straind or the persistence of paper
in health care work
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Print outs as display medium for quick reference for planning
and collaborative tasks Transcription of electronically available
patient data into paper notes To enable alignment with incompatible
systems (i.e. pharmacy) Temporary, handwritten data storage for
later entry into the computer (electronic observations)
Slide 18
Questions What methods can the sharp end and the blunt end of
health care organisations use to help detect unanticipated
consequences? How can organisations learn about unanticipated
consequences in their sociotechnical context? What methods can
social researchers use to generate knowledge to help organisations
anticipate consequences?