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Systems Thinking and Medication SafetySteve Peterson, BSN, RN-BC
Pharmacy Clinical Nurse Liaison SpecialistJanuary 6, 2015
Objectives• Provide a working definition of “systems thinking”• Describe the influence connections and social networks
have in complex systems and systems thinking
• Describe fundamental concepts of complexity science and complex adaptive systems
• Facilitate understanding of systems thinking concepts related to medication administration through a comparative illustration example
• Describe the importance of systems thinking principles in safe medication practices
The “Colorado Case”
(Smetzer, 1998)
Background• Male infant born October 1996 near Denver,
Colorado• penicillin G benzathine 50,000 units/Kg IM x 1• penicillin G 50,000 units/Kg
The “Colorado Case”• Processing the order• Dispensing the medication
The “Colorado Case”• Processing the order• Dispensing the medication• Preparation for administration• Medication administration
The “Colorado Case”• Processing the order• Dispensing the medication• Preparation for administration• Medication administration
Processing the Order• No pediatric pharmacist• Pharmacist on duty unfamiliar with treatment of
CS; little knowledge of the medication (rarely used, non-formulary)
• Reviewed the HD recommendation and consulted Drug Facts and Comparisons
Processing the Order• Misread dose in both as 500,000 units/Kg• Misread physician's order as 1,500,000 units• No warning when the dose entered into the
computer system• Dose of 1.5 million units was prepared…
Dispensing the Medication• 2 syringes; each syringe: Pen G benzathine 1.2
million units/2 mL with sticker: “Note dose strength”. No other warning labels.
• To administer 2.5 mL IM (1,500,000 units)– Correct dose: 0.25 mL (150,000 units)
Max IM Volume for Infant?
= 0.5 mL x 5 = 2.5 mL
= 0.25 mL (correct dose)
Dispensing the Medication• The med in one of the syringes had expired,
so it was replaced• Another pharmacist dispensed the med
without checking the original order…
Preparation for Administration• After noting the order, the bedside nurse and NNP researched treatment for CS• 1994 Red Book: Report of the Committee on Infectious Disease
• Offered Pen G benzathine IM as option• Did not state “IM only”
• Neofax ’95• Did not specifically mention PCN G benzathine, so no warnings for “IM only”• Aqueous crystalline PCN G slow IVP
• NICU Medication Administration (no mention of PCN G benzathine)• Decided 5 IM injections was too many… decided to consider IV route
Preparation for Administration• Hospital policy did not clearly define
prescriptive authority for non-physicians…• NNP thought she was acting under a national
protocol that allowed her to plan, direct, implement, and change drug therapy
Medication Administration• Neither nurse noticed that the syringes were labeled
with a manufacturer’s warning: “IM use only”• Manufacturer warning was 180º away from drug
name– Orange plunger in PF syringe concealed part of the “M” in
“IM”
Medication Administration• Both manufacturer and pharmacy labels expressed dose as
“1,200,000” instead of “1.2 million”• PCN G benzathine is white, milky substance
• Same as lipids…• No additional concern
• Began to give med via IVP…• After 1.8 mL the infant became unresponsive• Resuscitation efforts were unsuccessful
Who is to Blame???• Nurse?• Nurse practitioner?• Pharmacist?• Physician who wrote the order?• Staff who did not transcribe information
correctly?• Physician who did not write ID physician
recommendations before event?
Who is to Blame???Three nurses were indicted on charges of negligent homicide
Over 50 systems errors attributable!
“To do things differently, we must see things differently. When we see things we haven’t
noticed before, we can ask questions we didn’t know to ask before.”
- John Kelsch, XeroxWho???What!?!
We Are Products of Our Environments
Medication SafetyFive Rights:
1. Right patient2. Right drug3. Right dose4. Right route5. Right time
Four More??6. Right
documentation7. Right action8. Right form9. Right response
(Elliott &Liu, 2010)
Importance of Systems Thinking in Safe Medication Administration Practices
Safe medication practice involves multiple “systems”, connecting numerous individuals with varied influences (positive or negative), throughout which potential threats to process integrity and patient safety must be considered at each phase, up to and including final administration.
Systems Thinking“… understanding a system by examining the
linkages and interactions between the components that comprise the entirety of the defined system.”
(Institute for Systemic Leadership, 2014)
Systems Thinking“… takes into account the structures, patterns of
interaction, events and organizational dynamics as components of larger structures, helping to anticipate rather than react to events, and to better prepare for
emerging challenges.”
(Atun, 2012, p iv5)
Connected• We don’t live in groups, we live in networks (p.214)
• “Bucket Brigade” (pp. 214-215)
• “Human Superorganism” (pp. 289-292)
• Colony of ants• Cells in a multicellular organism• Social networks
• Memory• Turnover• “Self-annealing”
(Christakis & Fowler, 2009)
Networks
HIGH Transitivity LOW Transitivity
Connected
(Christakis & Fowler, 2009, pp 303-304)
Complexity Science“… a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents” (Plsek & Greenhalgh, 2001, p 625).
“… a way of thinking, behaving, and approaching care” (Bleich, 2011, p 254).
Complex Adaptive Systems in Healthcare
• “Fuzzy” boundaries• Actions based on internalized rules• Agents and the system are adaptive• Systems are embedded within other systems• Tension and paradox are natural phenomena• Continually emerging, novel behavior• Inherent non-linearity• Inherent unpredictability
(Plsek & Greenhalgh, 2001)
Wait… it gets even better!
I thought we were talking about Systems Thinking… and what does this have to do with medication administration???
Am I even in the right presentation?
Illustrating the Concepts of Systems Thinking and Medication Administration in Terms of Pathophysiological Aspects of
Cellular Responses to Injurious Agents
Oh, yes I did…Pathophysiology Systems Thinking
Environment
Tissue
Cell
Organelle
Materia
l
Environment
Department/Unit
Staff
Staff tasks
Data
Weakening of the SystemAtrophy (Cizaldo, 2010) Workarounds (Med Admin)
• Potential response to an “injurious agent”
• Shrinkage of cells
• Due to loss of “cell machinery”, not water
• Potential response to complex, time-consuming, or overwhelming situations
• Deviation from Standard of Care
• “Shrinkage” of tasks/duties
• Due to elimination of “steps”, not knowledge/responsibility
Potential CausesAtrophy (Cizaldo, 2010) Workarounds (Med Admin)
• Decreased blood supply
• Inadequate nutrition
• Change in hormonal stimulation
• Loss of innervation
• Reduction or inadequate “flow” of necessary components
• Decreased quality of essential components
• Change in process stimulation
• Impaired communication within network(s)
Results/ConsequencesAtrophy (Cizaldo, 2010) Workarounds (Med Admin)
• Production of autophagic vacuoles (lysosomes)
• Cell “machinery” reduced via auto-digestion, due to decreased demand
• Some particles are not digested; not removable (lipofuscin)
• Accumulation of lipofuscin can be life-long in some cells- esp. where cell division/replication does not occur
• Production of “pockets” of “enzymatic actions” within the process
• Steps eliminated (Value vs Non-value)
• “Remnants” or implications of the workaround (modified practice, reduced safety net, subtherapeutic vs toxic administration)
• Over time, bad habits and eliminated processes accumulate… e.g. “swiss cheese effect”
“Injurious Agents”When exposed to an injurious agent, the cell/tissue will try to adapt to overcome the agent.However, if exposed long enough, then the effects of the agent become too great, and there will be permanent damage.
(Cizaldo, 2010)
Injurious AgentsCell Pathophysiology (Cizaldo, 2010) Medication Administration• Hypoxia
• Chemicals/Toxins/Poisons
• Infectious agents (direct destruction, toxin secretion, hypersensitivity reaction)
• Immune response (over- or under-response)
• Nutritional imbalances
• Physical agents (abnormal temps, chemicals, pressure, ionizing radiation, etc…)
• Lack of “rights of medication administration” (How many??)
• Barriers to critical thinking and/or “blocking” the proper pathway or process
• Task overload/underload, attitudes, behaviors, practices, experience, and/or personalities
• System’s ability to compensate for threats
• Lack of adequate resource materials; not utilizing proper resources/references
• Environment of care…
Barriers to Critical Thinking• Frequent task switching and unpredictable demands
• Heavy cognitive load with little uninterrupted time• Conditions necessary for critical thinking are rare
• Similar to physician workflow research
• Interventions:• Lean design
• Duty reallocation/delegation
• Technology deployment
• Continuous education and training
(Cornell et al, 2011)
Swiss Cheese Effect
(Reason, 2010)
Systems Thinking… In Practice“… careful consideration of potential consequences of
policies and actions, generating scenarios through working and joint thinking: taking into account the
interactions between health system elements and the context… (p. iv5).”
(Atun, 2012)
Summary• Systems Thinking “Think globally, act locally”
• Everything is connected… your influence transcends your immediate actions
• Complexity Science 1 + 2 ≠ 3 (Parts < Whole)… Expect the unexpected
• Complex Adaptive Systems (Healthcare Environments) are unpredictable, interconnected, adaptive, and always evolving…
• “Injurious Agents” are numerous and always present a threat
• A “reporting culture” helps to build system “immunity”
• Medication administration is a critical component in patient care whereby a patient can be healed or harmed. YOU are often the deciding factor...
Importance of Systems Thinking in Safe Medication Administration Practices
Safe medication practice involves multiple “systems”, connecting numerous individuals with varied influences (positive or negative), throughout which potential threats to process integrity and patient safety must be considered at each phase, up to and including final administration.
ReferencesAtun, R. (2012). Health systems, systems thinking, and innovation. Health Policy and
Planning, 27, iv4-iv8. doi:10.1093/heapol/czs088
Bleich, M. (2011). Providing nursing care in a complex health care environment. In A. W. Davidson, M. Ray, & M. Turkel, Nursing, Caring, and Complexity Science: For Human-Environment Well-Being (pp. 253-262). New York, New York: Springer Publishing Company.
Christakis, N., & Fowler, J. (2009). Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives. New York, Ney York: Back Bay Books.
Cizaldo, G. (Performer). (2010). Biology 3020- Pathophysiology with Doc C. Duluth, MN. Retrieved November 2014
Cornell, P., Riordan, M., Townsend-Gervis, M., & Mobley, R. (2011). Barriers to critical thinking. Journal of Nursing Administration, 41(10), 407-414. doi:10.1097/NNA.0b013e31822edd42
Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: an overview. British Journal of Nursing, 19(5), 300-305.
ReferencesInstitute for Systemic Leadership. (2014). Basic principles of systems thinking as applied
to management and leadership. Retrieved November 2014, from The Institute for Systemic Leadership: http://www.systemicleadershipinstitute.org/systemic-leadership/theories/basic-principles-of-systems-thinking-as-applied-to-management-and-leadership-2/
Johnson, J., Barach, P., Cravero, J., Blike, G., Godfrey, M., Batalden, P., & Nelson, E. (2007). Improving patient safety. In E. Nelson, P. Bataldan, & M. Godfrey, Quality By Design: A Clinical Microsystems Approach (pp. 165-177). San Francisco, CA: Josey-Bass.
Plsek, P., & Greenhalgh, T. (2001). The challenge of complexity in health care. British Medical Journal, 323, 625-628.
Reason, J. (2000). Human error: models and management. British Medical Journal, 320, 768-770.
Smetzer, J. (1998). Lesson from Colorado: beyond blaming individuals. Nursing98, 28(5), 48-51.
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