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Reducing Medical Errors: A Review of Innovative Strategies to Improve Patient Safety.
Subcommittee on Health
Miss. Bonnie Westra PhD, RN
Good morning, Mr. Chairman and Members of the Subcommittee. I am Bonnie Westra, a registered nurse and former co-chair of the American Nurses Association's Committee on Nursing Practice Information Infrastructure, a committee of the Congress on Nursing Practice and Economics. Thank you for the opportunity to address medical errors and technology, important issues for every nurse. The American Nurses Association is the only full-service association representing the nation's registered nurses (RNs) through its 54 constituent member associations. Our members include RNs working and teaching in every health care sector across the entire United States. Numbering more than 2.7 million, nurses are the largest health care workforce in the nation. From the nurse midwives who attend delivery, to geriatric nurse practitioners who manage end-of-life care, to staff nurses who care for us during times of acute injury or illness, nurses are integral to health care across the human lifespan. Nurses touch patients and manage teams of healthcare professionals in hospitals, clinics, community health centers, offices, nursing homes and patient's homes, always seeking to have better outcomes. We are the ones who most often care for patients and manage the technologies incorporated into their healthcare experiences. Recent advances in medical technology have resulted in truly amazing treatments and procedures. These advances are extending and improving the quality of our lives. They are also increasing the complexity of health care. Just think of premature infants in neonatal units or the burn victims from the recent terrorist attacks; these patients are able to survive and thrive when only a few years ago they could not. Nurses in these units manage patients who are supported by heart-lung bypass machines, ventilators, and constant drug infusers. Patients such as these require constant monitoring, as even minute changes can quickly lead to disaster. Thus, today's nurses are engaged in painstaking, complicated care, with fewer supports than ever before and significantly increased potential for error. Error Error is defined as the failure of a planned action to be completed as intended (an error of execution) or the use of a wrong plan to achieve an aim (an error in planning). (IOM, 2000) Numerous opportunities for failure exist at many points in even the simplest healthcare experience. Nurses, in the role of patient advocate, often intercede to prevent system errors which may or may not result in patient harm. Appropriate technology applications can assist the nurse in these efforts to prevent medical errors. Conversely, those same technologies can compromise the healthcare delivery process and create even more adverse outcomes. The identification, resolution, and prevention of medical errors necessitates participation by every stakeholder, including registered nurses who are at the bedside, in examining and then improving the appropriate processes and systems. Such process improvement and re-engineering initiatives demand appropriate ongoing data collection and analysis strategies, implementation of standards and protocols to effect change, and measurement of outcomes that demonstrate success or failure in preventing the same or new types of error. Assessment of human factors associated with the proposed technology need appropriate attention. Computer-based information systems can assist in some of those activities. Healthcare Information Systems Current healthcare information system resources can prevent errors by removing unreadable handwritten orders and documentation. Errors can be significantly reduced if the information systems include decision-support capabilities such as direct internet access to journal articles and professional references, prompts and alerts, drug-drug or drug-food interaction alerts, "order set" templates, and care pathways/protocols and clinical guidelines. But such robust capabilities remain useless if nurses or other healthcare professionals do not have immediate access to the technologies, must engage in difficult and prolonged sign-on efforts, or have to "make do" with a documentation or order entry system that fails to meet their information needs. Inadequate orientation and skills at making the system work optimally further contribute to failures of the systems. For example, personal digital assistant devices (PDAs) or other larger handheld data entry units can aid in point of care data entry by nurses. However, if the available software applications do not support recording of standardized terms used to describe the assessments, diagnoses, interventions, and outcomes, nurses can not describe the patient, care activities and future plans. These elements are then lost to other nurses and healthcare professionals as they assume responsibility for patient care management. Similarly, lack of communications technology standards may also prevent effective information transmission to and from the PDA if network, software and hardware incompatibilities exist. And what about the practical aspects of the nurse having to carry yet another item in a pocket, in hand, or on a belt or waistband? Can the device accommodate right or left hand users? Are displays adequate for the viewer or must the nurse scroll through numerous screens to find the necessary information or data entry screen? Does the device remain charged long enough to allow completion of the necessary documentation or information seeking activities? Information systems and their software applications provide significant volumes of clinical and administrative data and information. However, in order to assure that the data is most meaningful and that it relates to the appropriateness of the patient's care, nurses must be integral to the design and development of the system. This ensures that information can be tapped for quality assessment initiatives aimed at identifying and preventing medical errors. The technology also provides the opportunity to reevaluate systems and processes already in place, as a means to reducing inefficiencies. Unfortunately, data cemeteries may be the more common result when information systems are unable to "talk" to each other or the reports can not be generated because documentation standards have not been implemented. Duplication results when the information gathered isn't accessible to all of the patient's providers, potentially contributing to increased healthcare costs and delays in patient care. These deficiencies are being targeted by HIPAA rules and various standards initiatives such as HL7, ASTM, ANSI, and DICOM. Voice Recognition Voice recognition technologies have been recommended for incorporation into healthcare practice settings to reduce medical errors when clinicians refuse or cannot complete manual data entry processes in an information system. Although errors caused by poorly written orders and documents have been removed with voice recognition systems, the potential for new medical errors emerges in the form of incorrect conversion of the audio file into digital content. When considering implementation of this technology to reduce medical errors, nurses find such a strategy less useful because of the concern for maintaining the confidentiality of patient information. Nurses are highly mobile healthcare professionals who frequently document assessments and caregiving information. They usually work in noisy and populated work centers, patient's private homes, and busy community clinics. Such locations do not support confidentiality of patient information that may be dictated into an information system microphone. Currently specific "machine" training for voice recognition systems must be completed for each individual user, not a small task for the regular and float nursing staff assigned to a busy hospital nursing unit or clinic. To further complicate any voice recognition system implementation plans, the current practice for registered nurses incorporates report activities that are completed at end of shift or at time of transfer of patient care to another provider. Therefore, this technological approach to medical error reduction and prevention could prove cumbersome and may be difficult to implement for this group of professionals. Barcode Technology Barcode technology is a mainstay within the business community and is now finally moving into the healthcare mainstream as a method to reduce medical errors. Potential uses include barcodes for supplies and pharmacy products, as well as unique patient, staff, and location identification labels. This technology can assist in ensuring the right patient receives the right medication in the right dose via the right route at the right time. Implementation delays will continue to occur until a single set of barcode standards are identified, acceptable hardware devices create reliable results, and healthcare professionals review business processes to identify junctures and activities that can benefit from safe and efficient barcode use within practice settings. Provisions must be made for effective backup strategies that must accommodate times of network or electrical power failures. For example, packaging of unit dose medications needs standardization of barcode labeling, an initiative being addressed by device vendors, pharmaceutical and pharmacy representatives, and must include consumers, nurses and other healthcare professionals. Education and Training Proper use of any technology involves correct preparation of the user. This may involve formal, or most frequently, informal or non-existent learning experiences. With increasing budget constraints, such educational opportunities are cut and users are expected to intuitively discover how to use the technology. Trial and error may be fine when learning how to use a computer, computer application, cell phone, PDA, or some other device or procedure in the privacy of the home, but is unacceptable in the dynamic hustle and bustle of a healthcare setting. Just in time learning is too late in a patient care emergency and increases the risk of error. Instruction manuals may not have been purchased, may not be current for the newest software application, or disappear if attached to the device. The paper or on-line manuals may not be understandable to the user as many frustrated cell phone users can attest. Human factors considerations may not have been incorporated in the learning materials. Healthcare professionals are obligated to maintain their skills, knowledge, and competence to provide quality care without errors. Academic preparation for entry into practice and continuing education professional experiences need to provide opportunities for acquisition and refinement of computer and information management skills, understanding of new processes and technologies, and the appreciation of prevention of medical errors and development of quality assessment and implementation programs. Addition of such curriculum content involves faculty preparation and funding for supporting technologies. Role of Standards Standards organizations, vendors, and healthcare professionals are partnering to integrate communications, documentation, and other standards into the healthcare environment to help prevent errors or reduce the impact of medical errors. By establishing recognized language and data standards, everyone can use the same terms with the same definitions and meanings and thereby prevent confusion and error. Standard product, procedure, and process naming conventions can then be programmed into information system software programs to permit the user to select the correct item. The recognized standards must accommodate all healthcare professionals in their practice. For example, recognized HIPAA code sets do not yet include complementary and alternative therapies, nor the diagnoses, interventions and outcomes terms used by registered nurses in their diverse practice settings. Incorporation of standardized language of practice will permit appropriate data collection and reporting, improved information management strategies, and knowledge generation activities. This supports incorporation of appropriate protocols and practice guidelines into practice to prevent errors and track outcomes and variances that may need to be identified as medical errors. The secondary review of clinical documentation about diagnosis, interventions and outcomes will finally permit more accurate accounting of actual or potential medical errors, whether an error in the planning or an error in the execution of the plan. Unique Patient Identifier Although not yet available and not considered a technology by some, the unique patient identifier is significant for nurses patients to prevent errors in the practice environment. Nurses care for patients across every setting and need to share extensive amounts of information about these individuals, groups, and populations with colleagues and other health professionals. Continuity of care between home health, hospital, long term care or hospice settings is a mandate. Reliance on name or hospital number does not help the nurse in confirming the correct patient information is being accessed or displayed when the individual uses the name Mary Smith today but was identified as Kathleen Mary Jones a month ago before her final divorce decree. Electronic Mail and Internet Access Internet access and electronic mail (e-mail) use associated with healthcare delivery continues to explode as consumers and healthcare professionals include these technologies in their daily lives. Consumers are using the billions of electronic worldwide web pages for information about health promotion, disease characteristics, and treatment options. Healthcare professionals respond to resultant consumer questions about care options and decisions and may use select available Web educational materials as quality patient education resources. Increasing reliance on e-mail communications, between clinician and patient or between clinician and clinician, opens new avenues for medical error prevention or generation, depending on the viewpoint. For example, patients can raise their questions before taking a dietary supplement or vitamin that may interact with a prescribed medication or treatment. Similarly, patients may alert the clinician of an observation or response that could become a significant problem if allowed to continue. However, on the negative side, use of electronic mail can create medical errors because this somewhat informal communication mechanism does not incorporate the checks and balances provided in the carefully tested, built in algorithms or rules-based order entry and documentation components of healthcare information systems. Similarly, medical errors may result when confidentiality and security measures, like public-key and encryption technologies, are not in place to prevent tampering or public disclosure. A unique patient identifier becomes even more important in this environment where e-mail addresses may be shared by multiple users and e-mail content should be linked to the appropriate patient's clinical record. Potential medical error opportunities exist in the arena of web-based personal health records. Internet services may broker patient health information stored on the website which may include marketing of inappropriate products to the individual that may result in medical errors. Potentials for incorrect reporting of laboratory or other results exist that then become parts of the individual's personal health record. Medical errors may occur if clinicians consider these results to be valid and reliable measurements and use them to make decisions about a patient's care. Culture and Context Incorporation of technology solutions into practice requires active integration by the healthcare professional in each work setting. The past practice has been to purchase the technology and then expect nurses and other healthcare professionals to welcome the new tools, gadgets, or processes. However, imposition of these solutions may not yield the preferred outcomes and may even result in the creation of medical errors. Careful evaluation of the setting before and after the implementation to validate the appropriateness of the technology solution and resultant outcomes occurs infrequently. This evaluation process, rarely done, must include examination of the impact of change on the organization's culture and patient outcomes within the healthcare system. Conclusion These few examples reflect the complexity of the medical errors issue. Although technology is most often presented as the preventive or curative strategy for medical errors, nurses find that not to be the case in most instances and view it as "technology looking for an application." "Quick fix" technology fails to address the systems and cultural changes necessary to maximize patient safety and care. Nurses strive to be partners within a non-punitive system that meets the needs of patients and reduces patient risk. They are the providers who will ultimately implement these new technologies and therefore need to play a substantial role in the development, implementation, evaluation and redesign of these systems. Their contribution is integral to prevention of medical errors. Reference Committee on Quality of Health Care in America, Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
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