The use of health technology has grown exponentially in the past few decades, and the proliferation and complexity of this technology has led to new risks to patient safety. In this interview with IHI Communications Specialist Jo Ann Endo, IHI Executive Director and patient safety expert, Frank Federico, describes the keys to success for using health technology safely. Frank helped develop the upcoming IHI Expedition on Improving Patient Safety with Health Technology.
Watch video with Frank Federico
Q: Why is technology and its role in patient safety a growing concern?
Technology is becoming such an important part of patient safety because health care providers implement more and more new technology all the time. For example, we have electronic health records (EHRs), computerized prescriber order entry (CPOE), barcoding, and medication administration equipment like pumps. The use of new technology brings with it new possibilities for error and harm — unintended consequences that we need to be aware of. As much as we want to use technology to enable us to do our work better, we can’t let it drive how we do our work. We can’t let use of technology unintentionally harm patients because we didn’t anticipate the possibility that harm could occur and put safeguards in place to mitigate it.
I’m not saying that technology’s not good. Technology can be great — it can help us do many things to help keep patients from harm, but we have to implement it well. The Institute of Medicine 2011 report, “Health IT and Safety,” talked about health technology as part of a “sociotechnical system,” and how safety comes out of the interaction between factors in that system, including technology, people, processes, organizations, etc. In other words, good implementation includes the clinicians who are going to use the technology, the IT department that supports the system, and the vendors who are helping to implement the system.
Q: Improving clinical alarm safety is a Joint Commission National Patient Safety Goal. Why is alarm safety is an important issue?
Visit an emergency room or a general ward, or practically any unit in a hospital, and you hear alarms going off all the time. When I was recently in the emergency room at a local hospital, alarms were going off and nobody was doing anything about them. It makes you stop and wonder if people have become immune to the alarms because there are so many of them. Is it that people don’t hear them anymore? Or are they ignoring them because so often the alarm doesn’t really require attention? But what about those times when the alarm is signaling something important? The Joint Commission identified alarm safety as an important issue because there have been some deaths documented as a result of not responding to alarms appropriately. The challenge is that it is such a pervasive problem and it’s unlikely that we can solve it with one solution.
Q: Have any organizations had success with addressing this issue of alarm safety?
Boston Medical Center used a wonderful approach. First, they segmented and focused on one particular patient population — patients in the cardiac ward. Then they looked at the kinds of alarms that were going off in that ward, and determined which were critical and which were not. They decided they could turn off some of the minor alarms without risking patient safety. They’ve found that this change has made it easier for clinical staff to hear and pay more attention to the most critical alarms. Addressing so-called alarm fatigue also provides patients with a quieter environment. Alarms are constantly disturbing patients, and studies indicate that quiet time helps patients heal. How can we take the lessons learned in the cardiac ward and bring that learning to improve clinical alarm safety in other areas of the hospital? That’s what we need to learn.
Q: There are some clear advantages to using electronic health records, but what are the most common potential safety hazards with using this technology?
When the patient safety movement got started years ago, one key idea for helping to decrease harm was making the patient’s health record easy to access. The gold standard seemed to be an electronic health record. Years later, we’re finally at a point where most hospitals in the United States are implementing electronic health records, but — along with their advantages — they also have a whole new set of problems. For example, simultaneously opening multiple patient EHR profiles and mistakenly inputting notes into the wrong patient’s profile. Another issue is that some clinicians are copying and pasting the same notes over and over again. If there’s an error in the original note, you just end up repeating it.
Q: What are the some of the most important factors for using technology safely?
There are a number of keys to success for safely using health technology:
Understand the human interface: How do humans work with the equipment? Is it easy to use? If you need to spend a lot of time training staff on using that technology, it might be too complicated.
Develop a system for learning: How do you make adjustments if a problem develops? The problem may happen in one unit, but everybody else in the hospital who uses the technology should be aware because it might be happening elsewhere or could happen in the future, so the system as a whole needs to address the issue.
Provide appropriate training: I have my own personal bias around how much training you should have. As I said earlier, if you need hours and hours of training, maybe you need to use simpler technology. I like to ask people, “Did you need training to use a store self-checkout?” They usually laugh and say, “Well, no, because it’s intended to be easy to use.” Shouldn’t that ideally be true for health technology? A smart phone is a complex device, too, but manufacturers design them to be easy to use.
Provide good user support: Even with good training, you need good user support. Train “super users” who really know how to use the technology, and who are readily available to answer questions. You can’t anticipate every issue that might arise during training, so it is really important to have staff who are very knowledgeable about the technology and are available to help with actual use.
Q: What about the issue of using workarounds and their safety implications?
Workarounds are an important safety issue that we too often forget. They develop when a process or a technology doesn’t work properly, or is too difficult or too time-consuming to use. If you don’t identify and remedy the reasons that workarounds develop, people will continue to use workarounds to the point that the safe system you thought you had in place is no longer safe. It’s one of the reasons you need a system for learning.