Role of Technology in Improving PS

• Computerized Physician Order Entry

(CPOE).

• Bar-code Medication Administration

(BCMA).

• Radio Frequency Identification

(RFID).

• Abduction/Elopement Security
Systems.
 Role of Technology in Improving PS

• Clinical Decision Support

System (CDSS).

• Infusion Pump.

• An electronic health record

(EHR), or electronic medical
record (EMR).
 Computerized Physician Order Entry
(CPOE)
• CPOE is a form of patient
management software.

• CPOE is a process of
electronic entry of
medical practitioner
instructions.
 Computerized Physician Order Entry
(CPOE)
• CPOE was recommended
to be implemented in the
To Err is Human report and
was one of Leapfrog's first
standards.
 Computerized Physician Order Entry (CPOE)
• Most systems interface with
clinical decision support systems
(CDSSs), which include
suggestions for drug doses,
routes, and frequencies and may
also check for drug allergies,
drug- drug interactions, drug-
laboratory values, drug
guidelines.
 Bar-code Medication Administration
(BCMA)
• BCMA is a barcode system
designed to prevent medication
errors in medication
administration.

• It consists of a barcode reader, a

computer with wireless
connection, a computer server,
and some software.
 Bar-code Medication Administration
(BCMA)
• Seamless integration with an
electronic medication
administration record (eMAR),
pharmacy system, and the
organization's information
system.

• Warning/Alert when indicated.

 Radio Frequency Identification (RFID)

• Radio-frequency
identification (RFID)
is the wireless use of
electromagnetic
fields to transfer
data.
 Radio Frequency Identification (RFID)
• a type of automatic
identification system,
using digital memory
chips embedded on tags
to track medical devices,
drugs, staff, patient, and
so forth.
 Radio Frequency Identification (RFID)

• Each chip has a unique

electronic product
code.

• The tags contain

electronically stored
information.
 Radio Frequency Identification (RFID)
• In healthcare, RFID is
utilized for three
purposes: asset
management, patient
care, and inventory
management.
 Radio Frequency Identification (RFID)
• Patient care uses:

- Tracking patients who wander,

or leave the unit for testing,

- patient identification,

- surgical sponge and instrument

tracking when closing a surgical
incision, and so forth.
 Radio Frequency Identification (RFID)
• Utilized in abduction and
elopement systems.

• The tag may contain information

about the lot number and
expiration date for medical
supplies and drugs or allergies
and blood type for patients.
 Radio Frequency Identification (RFID)
• It has both read and write
capability, whereas barcoding
is read only.

• A disadvantage of RFID is the

expense of the equipment,
both hardware and software.
Abduction/Elopement Security Systems
• Active RFID technology is used
increasingly for infant and
pediatric security to prevent
abduction.

• Abduction prevention systems

usually have a soft self-adjusting
bracelet that is placed around the
infant or child's wrist or ankle.
Abduction/Elopement Security Systems
• If the bracelet is removed
or cut off, an alarm signals
the nursing station and
computer software,
alerting the healthcare
staff.
Abduction/Elopement Security Systems
• Usually the facility incorporates
door and elevator locks, and
goes into "lockdown mode", if
a bracelet is removed or if
someone attempts to take the
infant/child through the door
or down the elevator with the
bracelet still on the child.
Abduction/Elopement Security Systems
• Some systems utilize a
mother/infant matching
system, where the mother is
given a tag or band with the
same code as her infant's, to
serve as an additional and
automatic identification.
Abduction/Elopement Security Systems
• This is generally helpful in settings
where patients/residents have
cognitive impairment.

• If a patient or resident approaches

an exit, the door controller locks
the door; if the door is open, an
alarm sounds.
 Infusion Pump
• An infusion pump infuses
fluids, medication or
nutrients into a patient's
circulatory system.
• It is generally used
intravenously, although
subcutaneous, arterial and
epidural infusions are
occasionally used.
 Infusion Pump

• Infusion pumps can

administer as little as
0.1 mL per hour
injections (too small for
a drip).
 An electronic health record (EHR), or
electronic medical record (EMR)
• It is a record of electronic
health information in
digital format that is
theoretically capable of
being shared across
different health care
settings.
 An electronic health record (EHR), or
electronic medical record (EMR)
• EHRs may include a range of
data, including demographics,
medical history, medication
and allergies, immunization
status, laboratory test results,
radiology images, vital signs,
personal statistics like age and
weight, and billing information.
 Health Technology Hazards
• This should cause organizations to
place additional attention on
these items.

1. Alarm hazards: inadequate alarm

configuration policies and practices.

2. Data Integrity: incorrect or

missing data in EHRs and other
health IT systems.
 Health Technology Hazards
3. Mix-up of IV lines leading
to misadministration of
drugs and solutions.

4. Inadequate safety of
endoscopes and surgical
instruments.
 Health Technology Hazards
5. Ventilator disconnections.

6. Patient-handling device
use errors and device
failures.

7. Robotic Surgery.

8. Cybersecurity.
 Human factors engineering
• Methods for Improving Patient Safety.

• Interactive systems that involve

people, tools and technology, and

work environments.

• The top three factors that contributed

to the errors were cognitive factors.

Communication failures ranked

fourth.
 Human factors engineering

• Since individual human factors are

substantial to preventing errors, there

must be focus on individuals, in addition

to focus on the system.

• Cognitive factors and communication

failures are therefore the highest priority

areas of focus when working to mitigate

these types of errors.

 Human factors engineering

• Identify and address human

issues; focus on mitigating the
cognitive and perceptual errors,
taking into account human
strengths and limitations in the
system design to ensure safety,
effectiveness, and ease of use.
 Principles of human factors engineering

• Simplify.
• Usability testing.
• Standardize.
• Use forcing actions and
constraints.
• Use redundancies.
 Principles of human factors engineering

• Avoid reliance on
memory.
• Encourage teamwork.
• Automate carefully.
• Use visual controls.
• Mistake proofing.
 Mistake proofing
• Mistake proofing, or its Japanese

equivalent poka-yoke, is the use

of any automatic device or

method that either makes it

impossible for an error to occur

or makes the error immediately

obvious once it has occurred.

 Mistake proofing
Examples:

1. The elevator will not move if out of

load.

2. Packaging medicines in plastic

bags containing a single dose, or "unit
dose, “ stops drug overuse.

3. Lock won’t operate when the car

doors are open.
 Mistake proofing
Examples of Mistake-Proofing in
Health Care:
• Infant Abduction Prevention.

• Bar Coding.

• Computer-Aided Nutrition and Mixing

• Private Files.

• Computer Drug Interaction Checker.

• Computerized Physician Order Entry.

 Mistake proofing
Examples of Mistake-Proofing in
Health Care:

• Plug Protection.

• Unit Dosing.

• Kits.

• Auto Shut-Off Treadmills.

• Needleless Systems.

• Distinct Labeling.
 Red Rules Examples
• "No hospitalized patient can
undergo a test of any kind,
receive a medication or blood
product, or undergo a procedure
if they are not wearing an
identification bracelet.“

• Time Out.
 Sentinel Event Process
• Sentinel event policy.

• RCA.

• The top four root causes were

human factors, leadership,
communication, and
assessment.

• Action.

• Apology & Disclosure.

 Apology & Disclosure
• When an adverse or sentinel
event occurs, All healthcare
organizations must have a
formal process for apology and
disclosing this information to
the patient and as appropriate
to family members, and to
those responsible for patient
safety within the organization.
 Apology & Disclosure
• Support systems to assist
the patient and providers
with this process must be in
place.

• Communication with the

patient should be timely,
within 24 hours of the
event if possible.
 Apology & Disclosure
• Communication should include the
facts about what happened,
empathic communication of those
facts and expression of regret ‫ندم‬, a
commitment to investigate and, as
possible, to prevent future
occurrences of the event, and that
emotional support of the patient
and family will be provided.
 Apology & Disclosure
• Caregivers are often called the

"second victim" of the event.

• There may be multiple

individuals who directly and

indirectly contributed to the

adverse event occurrence, due

to system failures or human

error.
 Apology & Disclosure
• The individuals involved in the

event either directly or indirectly

should be treated with respect and

dignity ‫كرامة‬.

• Those involved in the error receive

the care they need and to

determine if they are "fit to work"

for the protection of them and

others.
 Apology & Disclosure
• The exception would be if

they were found to be

under the influence of

drugs, or alcohol, or if their

behavior indicated that they

may have intentionally

contributed to the error.