This is part two in a two-part series on human factors engineering and its impact on patient safety. Go here to read part one.
Human Factors Engineering (HFE) principles are often being applied to the design of healthcare information technology (HIT).
HFE is defined by the Human Factors and Ergonomics Society as the "scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance."
As HIT increasingly becomes a part of clinicians' everyday jobs, it's important to consider their design. If HIT is not designed with the end-user or end-facility in mind, it may fail at facilitating patient safety.
Ross Koppel, PhD, thinks that most clinicians are amenable to using HIT, but the current technology systems make doing so effectively difficult. Koppel is professor of sociology at the University of Pennsylvania in Philadelphia and principal investigator on the study of the hospital as a workplace and medication errors at the Center for Clinical Epidemiology and Biostatistics at the UPenn School of Medicine.
"People in IT often denigrate the clinical staff as being incompetent people," says Koppel. "There's a share of blame, but my experience has been that clinicians actually want to do very good work and they find the IT to be a barrier too often."
Koppel was the lead author on a 2008 study published in the Journal of the American Informatics Association titled "Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety." He was intrigued by vendors' claims that barcodes reduced medication errors to virtually 0%.
"That, of course, was just a test of the printing of the barcode, it had nothing to do with the actual administration," says Koppel. "It's like saying if your car never leaves the factory it will never get into an accident. That's true—on the other hand, of what value is that?"
He and his colleagues examined the reasons that some clinicians used work-arounds in conjunction with barcoded medication administration systems (BCMA). To do this, they characterized each work-around as a specific type and compiled the data. BCMAs are supposed to help ensure timely administration of the correct type and amount of medication to the correct patient.
Koppel and his colleagues identified 15 reasons why clinicians needed to use a work-around, accounting for 4.2% of patients. These reasons ranged from technology-related (not having enough scanners necessary to read barcodes and computer connected to scanner not able to fit into patients' rooms) to task-related (clinician threw away packaging accidentally, which prohibited scan), to organizational (patient missing legible wrist band and medication missing a legible bar code) among others.
"All of the work-arounds—and all of them are justified given the problems with the software—all of those are work-arounds that severely deteriorate the patient safety protections," says Koppel.
By examining where these work-arounds occurred, four of the hospitals included in the study were able to dramatically reduce the amount of overrides by analyzing why clinicians were using the work-arounds and deciding on system repairs.
"For instance, if a doctor ordered 20 mg of a pill, and the pharmacy sends up two 10 mg tablets," says Koppel. "The nurse scans the first 10 mg tablet and the bar code says, 'That's no good; I'm looking for a 20,' and the nurse is screaming, 'But 10 and 10 equals 20.'"
The facility could write a software patch that tells the scanner that the two pills equal the total amount prescribed, he says.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.