Friday, May 15, 2015

We Really Do Need To Be Paying More Attention To The HIT Safety Issues.

I spotted this from one of our local experts this week.

In Conversation with…Enrico Coiera, MB, BS, PhD

Editor's note: Enrico Coiera, MB, BS, PhD, is a professor and director of the Centre for Health Informatics (Australian Institute of Health Innovation) at the University of New South Wales. Dr. Coiera has researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
 This interview can be heard by subscribing to the AHRQ WebM&M Podcast (.MP3 | 11.9 MB | 8 minutes, 40 seconds)
Dr. Robert Wachter, Editor, AHRQ WebM&M: How big a problem are interruptions and distractions in the world of patient safety?
Enrico Coiera: Interruptions happen every day to every clinician, nurse, and doctor. It's become clear over the last decade that in some clinical settings, not only are interruptions frequent but they're also a patient safety risk. We're not saying every interruption is a bad interruption, but we do know that for certain places and times, they can lead to significant patient risk.
RW: Which areas have the highest risk?
EC: The challenge is in understanding why interruptions can cause harm. They essentially disrupt working memory with the consequence that you can forget to do what you're about to do or, very oddly, repeat the task you've already done. For example, you might have administered a medication to a patient and then been interrupted, but because you do the task so often any individual act is not particularly memorable, and you give the same dose again.
An interruption can also result in the interrupted task being incorrectly executed. My classic example is driving to the shops on a Saturday morning, when the cellphone goes off. By the time you've finished your call, you don't find yourself at the shops but instead in the car park at work. The call has occupied your attention and because you are distracted, you follow an initially similar, but ultimately wrong plan, which dominated because it is well rehearsed and easily enacted.
Psychology tells us certain variables predict higher risk of memory disruption. Probably the most important is working memory load, which is governed by many things you have to remember at any one time, and how complicated each is. If a task involves mental calculation or many steps, then your working memory load will be high and thus put you at more risk of disruption by interruption. Another issue is if the interrupting task is very similar to what you're currently doing, this also increases the risk that it will lead to memory disruption.
Another variable is the interruption modality—is the interrupting task visual or auditory for example? Those modalities are processed differently in the brain. It's quite possible to be talking about one thing and looking at a something different, to multitask. If the interruption uses the same modality however, like two visual tasks, then you have more chance of one disrupting the other. The final variable is how good you are at the task you're doing. If you have a lot of practice and experience, your opportunity to do well with interruption increases.
So, the kinds of clinical tasks that we worry about include administering medications, preparing injectable chemotherapy and IVs, induction of anesthesia, or putting a central line in. They're all tasks for which cognitive and task variables suggest that they are at risk of disruption by interruption.
Lots more here:
Well worth a listen!

1 comment:

Karen Dearne said...

Interesting and pertinent. Not much consideration has been given to broader workflow safety issues. I have often pondered the risks of slavishly following electronic instructions.

Before Easter, I sent a parcel to my grandkids in Iceland. When it didn't arrive on time I checked the receipt from local PO. It said the parcel had been sent to Ireland, world zone 6, instead of the correct European zone 7.

A human input error. Thereafter followed increasingly surreal conversations with Oz Post international "help" lines where I really struggled to explain the parcel was destined for Iceland with a C and not Ireland with an R.

After their investigation I got a very unreassuring email explaining that they were confident the parcel would get to the address in Ireland safely!

Daughter checked with her local PO and was told it was not at all uncommon for mail addressed to Iceland being sent instead to the Emerald Isle

Parcel finally arrived this week, after a giant detour courtesy of a scanning error which took people weeks to identify and rectify.

Once something is in the system it can be hellishly difficult to put things back on track