I’ve Been Thinking about the power of “un” for analyzing, selecting, implementing, and using patient-safety technologies wisely

April 1, 2008 | In: I've Been Thinking

I’ve been thinking about the power of “un” for analyzing, selecting, implementing, and using patient-safety technologies wisely.

It all begins with understanding the relative value of addressing one point of risk before another. For example, six times as many medication errors reach patients from mistakes in administering than in dispensing drugs. Therefore, hospitals stand to achieve greater safety gains by implementing bar-code point-of-care (BPOC) systems than by replacing or adding automated dispensing machines (ADMs).

I wonder if our friends at Cedars are questioning their technology priorities over the past few years. Last November, adult doses of heparin would not have reached the three babies in the neonatal unit had either ADMs or BPOC been purchased and put to work and properly used. Instead, Cedars spent a reported $34 million and countless hours over several years on developing a computerized prescriber order-entry (CPOE) system, which they canned three months after implementation. Users reported the technology created more opportunities for error than were mitigated. Oh, as valuable as CPOE can be, even the best system would not have prevented the heparin errors.

Rushing to decision has hindered too many hospitals from acquiring next what they need the most.

After settling on the best next technology to apply, it is important for hospitals to uncover the benefits of one product over another. For example, all bar-code point-of-care products are not created equal. The same is true for CPOE systems and ADMs. Some provide more decision support, are more user-friendly, and integrate with other clinical systems more effectively than others. The people that will use and support these systems (e.g. nursing, pharmacy, IT, admissions, etc.) should have sufficient hands-on real-life evaluation exercises so they can identify the products that are right for them.

Once hospitals have identified the right things to do, they must remain undistracted in doing them. Years ago I read a booklet entitled The Tyranny of the Urgent, proposing that too often “urgent” things distract us from finishing important things.

My own attention deficit disorder is revealed by the fact that I am watching CNN even as I write. Barak Obama just referred to what Dr. Martin Luther King Jr. called “the fierce urgency of now.” While Obama was referring to his own reasons for running for president, the line made me think about how procrastination is costing patient lives.

“Picture yourself as a Cedars executive,” blogs Mr. HIStalk, “trying to explain to a belligerent lawsuit attorney that you know bar coding could have prevented somebody’s death, but you chose not to buy it.” (Brev+IT Weekly, November 24, 2007, histalk.com)

Hospitals are too easily distracted from completing the truly important things. Maybe a dose of Ritalin is in order.

Finally, once the right technologies are up and running, hospital leaders must be unwilling to tolerate caregiver’s using them the wrong way or failing to use them altogether. For example:

Employing ADMs is wise but not enough. Pharmacists, technicians, and nurses need to comply with carefully thought-through stocking and dispensing policies. Thanks to the ISMP for recently providing much-needed leadership in drafting Guidelines for the Safe Use of Automated Dispensing Cabinets. These guidelines are on target. We need to make sure they don’t stay on the shelf.

Implementing smart-infusion pumps is a smart move. However, it would be foolish for hospitals to skimp on the effort and funding required to adequately train nurses, measure compliance, and enforce zero tolerance for circumventing safety software.

BPOC is a brilliant move but only if systems are put in place that make workarounds difficult and addresses them whenever they occur. To this end I look forward to seeing many of you at The unSUMMIT for Bedside Barcoding in Austin TX at the end of this month (April 30 through May 2). Nothing is so empowering as learning from and networking with colleagues who have experienced the power of un in their hospitals— who believe unsafe is unacceptable. We’d love to have you with us.

What do you think?

Mark Neuenschwander

Copyright 2008 The Neuenschwander Company

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