Running head: COMPREHENSIVE EXAM

Comprehensive Exam: Culture Safety Jennifer R. Williams Ferris State University

COMPREHENSIVE EXAM Abstract This paper defines informatics and the utilization of technology to protect patients against errors while maintaining culture safety and quality of care. The benefits of health information technology (HIT) are evident and three positive examples of its use are provided. However, even with its benefits information technology may lead to an increase in errors. Two frequent concerns related to the usability and design of HIT are also provided. Examples of two quality improvement strategies to prevent error, maintain culture safety, and improve quality of care are then identified. The utilization of Lewins theory was utilized to support these strategies. Evaluation methods including the Likert scale, interview, and IDPAS checklist are identified to measure outcomes along with an explanation for their use. However, it is stressed that individuals should not rely too heavily on technology when immediate harm is expected and that human knowledge and intuition should be encompassed during these times. A summary of the main points is provided.

COMPREHENSIVE EXAM Comprehensive Exam: Culture Safety Maintaining a culture of safety and preventing medical errors is crucial to the healthcare environment. In addition, individual and organization accountability is essential to improve quality of care (Myers & Shannon, 2012). Healthcare informatics technology (HIT) has achieved a new significance in the United States healthcare system since the initiation of the American Recovery and Reinvestment Act (ARRA) of 2009. With new requirements for the increased integration of HIT, culture safety and quality of care are also a significant focus (Hersh, 2009). Through the application of informatics, the reduction of medical errors and improved safety is possible. Informatics is defined as the discipline that focuses on the storage and utilization of any information gathered through HIT (Hersh, 2009). To compare, nursing informatics is the integration of nursing knowledge, technology, and information into nursing practice. The informatics nurse specialist (INS) manages and incorporates these components into the clinical environment through collaboration and communication (ANA, 2008). The INS encompasses HIT and integrates technology knowledge into clinical practice through data collection and analysis. This data is then utilized to formulate recommendations and practices to enhance care quality through informatics (ANA, 2008). The introduction of informatics into the clinical environment has had a positive influence on creating a culture of safety and improving patient care outcomes (Huckvale & Akiyama, 2010). Examples of HIT that have been found to improve patient safety include the electronic health record (EHR), computerized clinical decision support (CCDS), and

COMPREHENSIVE EXAM computerized physician order entry (CPOE). Each of these styles of HIT have the ability to assist in decreasing potential medical errors; however the utilization of technology in healthcare can also produce potential problems and risks to culture safety. In turn, this can have a direct impact on the quality of care (Huckvale & Akiyama, 2010). The purpose of this paper is to discuss how informatics and the use of technology assist in protecting patients against medical errors. There is also a focus on maintaining culture safety to promote quality of care. In opposition, problems with HIT that may lead to an increase in errors will also be reviewed. There will be an example of two strategies in quality improvement to prevent error, maintain culture safety, and improve quality of care. An appropriate change theory to support the strategies will be provided. A plan to evaluate the outcomes of each strategy will also be given. The importance of trust in human knowledge instead of relying on technology will be explained. There will be a summary provided of the main points. Informatics Protection The protection of patients from medical errors is a critical care intervention that should not be taken lightly (Radecki & Sittig, 2011). Medical errors can be defined as adverse clinical events that can pose significant harm to patients. These errors can significantly affect patient safety and outcomes. Some areas of focus for medical error prevention include wrong patient, hospital-associated infections, wrong medications, and inadequate communication. The utilization of HIT to assist in error prevention can promote a culture of safety and improve patient outcomes (Radecki & Sittig, 2011).

COMPREHENSIVE EXAM Electronic Health Record The successful implementation of an EHR in the hospital setting can improve quality of care and promote safety. Better care coordination, improved nursing care, and efficient care delivery are all components that are expected with EHR implementation. Patient safety is supported by efficient nursing care, decreased medication errors, and improved patient care coordination. It is evident that the EHR is now an essential component to patient culture safety and quality outcomes (Kutney-Lee & Kelly, 2011). Computerized Clinical Decision Support CCDS compares entered patient data and clinical knowledge to a computerized knowledge base. The CDSS is able to make recommendations to clinician users by generating significant patient-specific needs. Clinicians are then able to support patient care with advanced clinical strategies. In addition, if effectively integrated with CPOE and the EMR, CCDS has the potential to assist in the reduction of medical errors. This process has been recognized to improve clinical interventions and enhance both patient safety and care quality (Jao & Hier, 2010). Computerized Physician Order Entry Medication errors can be a significant concern in the healthcare environment, although with the creation of CPOE these errors are now considered preventable. CPOE systems have been proven to sustain culture safety through the reduction of adverse drug events (ADE). The effectiveness of these systems has been linked to the integration of support tools like CCDS systems. With CPOE, clinicians are automatically informed regarding possible drug interactions, inappropriate dosages, and allergies. In addition to

COMPREHENSIVE EXAM these notifications, clinicians can also receive notifications for duplicate orders and medication related lab orders (Saxena, Lung, & Becker, 2011). The management of multiple types of HIT is a primary element for the incorporation of nursing informatics in the clinical setting (ANA, 2008). The nursing informatics specialty requires specific techniques and methods to support patient care efforts to improve quality of care and patient outcomes. The INS communicates the need to integrate HIT into the clinical environment to improve the risk of error and support patient safety (ANA, 2008). Informatics Problems The safety and effectiveness of technology can be directly related to both system design and usability (Sittig & Singh, 2011). Despite the literature on the positives of HIT, possible safety concerns have also been linked to its use. HIT errors have a high potential to sever culture safety and put patient outcomes at risk. This can be directly related to the high potential for harm in large numbers. Frequent triggers of errors include (1) unavailability of the system, (2) incorrect utilization of the system, (3) incorrect data entry, (4) inadvertent transmission, (5) system to system interaction issues, (6) or system design (Sittig & Singh, 2011). It is essential that the INS identify issues related to the utilization of HIT. Problems should be addressed when appropriate with the facilitation of a plan for resolution. Assessment data should be appropriately utilized to define the problem and make a determination for improvement. Collaboration and communication with key stakeholders and interdisciplinary teams is essential to produce effective change (ANA, 2008).

COMPREHENSIVE EXAM System Design Patient safety risks will continue to be relevant related to HIT design. This issue may be directly related to the initial development of the system. During the implementation phase, the system may be unable to support the user intentions or make appropriate options available to the user. This can often result in an inaccurate depiction of the information and thus create the possibility of error. (Chapman, Taylor, & Wood, 2010). As an example, electronic notes can pose potential errors related to patient safety through inappropriate system structure. This type of documentation can create care interface issues affecting both workflow and communication. Potential inconsistencies related to this open-ended style of documentation are a significant concern. It is also often difficult to depict the current state-of-health of a patient through an inflexible canned-text format with low readability. Inaccurate historical content through utilization of a copypaste system can also cause misinterpretation and errors (Liebovitz, 2009). User-System Interface Error potential is not necessarily defined by only the software, but can also be initiated by the end-user; patients, nurses, clinicians, and other validated users (Sittig & Singh, 2011). Human factor associated medical errors can be affected by the users clinical knowledge, computer literacy, and perception of the information. These types of errors are typically labeled as execution errors. In these cases, there is a human-computer synchronization issue where inaccurate information is entered or retrieved inappropriately (Chapman, Taylor, & Wood, 2010). For instance, a user may inadvertently abstract patient information from the wrong patient chart and utilize that information during the execution of care on another patient.

COMPREHENSIVE EXAM This could precipitate multiple execution errors including wrong patient, wrong medication, or wrong treatment. Similarly, a user may enter inappropriate information on the wrong patients chart and trigger future errors regarding misinterpretations by the subsequent user (Chapman, Taylor, & Wood, 2010; Sittig & Singh, 2011). Strategies for Quality Improvement System Design The development of a culture of safety requires commitment by the organization and the adoption of fundamental safety principles. The design, establishment, and appropriate maintenance of HIT will maintain a culture of safety at all levels (Kilbridge & Classen, 2008). The INS will coordinate the implementation of HIT to achieve desired outcomes (ANA, 2008). This strategy for HIT implementation can make fundamental contributions to safety through appropriate HIT design, usability, and integration (Kilbridge & Classen, 2008). During the process of system design there should be a commitment to communication and multidisciplinary teamwork. The INS will organize interdisciplinary informatics collaboration through leadership (ANA, 2008). Information technology, nursing, quality, and administrative departments should all be represented during the HIT design process. The INSs will partner with all required disciplines to enhance quality of care through technology development (ANA, 2008). A complementary approach to collaborative design is test simulation of the system. The INS will consider HIT factors related to safety, effectiveness, and impact on clinical practice (ANA, 2008). Creating a culture of safety with HIT design will require that the system have strong usability amongst all disciplines that require it. Participation of the INS

COMPREHENSIVE EXAM in continuous improvement regarding the design and development of HIT will be essential to successful HIT implementation (ANA, 2008). The final step to the safe delivery of HIT in the clinical environment is integration. Staff education is a significant component to this step (ANA, 2008). The INS will identify the need to integrate HIT through learning resources. Adequate education content and teaching strategies are necessary to encourage HIT acceptance (ANA, 2008). Having a successful HIT design that supports usability in the clinical setting will support a culture of safety and quality care (Kilbridge & Classen, 2008). User-System Interface The INS maintains knowledge and skills regarding human behavior through communication and relationship management (ANA, 2008). Human factors related to the use of HIT can be a challenging barrier to overcome (Saleem et al, 2009). The integration of a CCDS system is an example of clinical activity that could precipitate issues related to human factors in informatics. Decision support technology can cue user reception with data analysis and interpretation of information. These systems can also remind clinicians of the need for decisions regarding treatment and care (Saleem et al., 2009). CCDS systems can incorporate clinical reminders as well. User-interface support may include alerts of errors, order checks, documentation templates, and links to support tools (Saleem et al., 2009). Nursing informatics is needed to support both clinical and nonclinical efforts of nurses to improve care quality. The INS will incorporate humancomputer interaction and usability concepts into the HIT selection process (ANA, 2008). During the selection process, work domain analysis will be essential to the successful selection of a support system (Saleem et al., 2009). As with any informatics

COMPREHENSIVE EXAM project, all pertinent disciplines should be involved (ANA, 2008). Cooperation and support from IT, nursing, quality, and administration departments are essential. The INS will collect information through collaboration and workflow analysis to identify the need for an informatics solution (ANA, 2008). Usability testing should also be performed prior to choosing a system to determine environment compatibility (Saleem et al., 2009). Through observation and reflection, the INS will support the integration of human-technical factors to enhance the decision-making process (ANA, 2008). Once an appropriate system is chosen for implementation and integrated into practice, significant improvements in culture safety and care quality should be identified (Saleem et al., 2009). Theory Integration HIT changes rapidly in todays healthcare setting (Manor, 2010). Lewins theory of change will be utilized to support safety culture change in the clinical environment. This theory has three stages: freezing, moving, and refreezing. The idea of this theory is to stop current practices, learn the new practices, and implement the new practices. The plan to change current technology or integrate new technology will benefit from a framework that encourages change (Stevens, Bader, Luna, & Johnson, 2011). The Lewins theory of change is often utilized to build confidence in healthcare staff by allowing time to learn the new systems prior to implementation (Manor, 2010). During the unfreezing phase a goal is set to create motivation for change by preparing involved disciplines in the planning process. The moving phase includes usability testing and education of involved disciplines on the new forms of HIT. The refreezing phase

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COMPREHENSIVE EXAM consists of integrating the new system into clinical practice and evaluating the usability and success of the system to reduce errors and improve quality of care (Stevens et al., 2011). Outcome Evaluation User-System Interface Engagement in outcome evaluation assists in creating a safety culture and improving quality of care. The INS will participate with interdisciplinary teams to evaluate the outcomes of HIT (ANA, 2008). After the implementation of the new HIT design, an appropriate method to determine outcomes will used be to evaluate design appropriateness through evaluation and interviews (Horsky et al., 2010). A Likert scale survey will be utilized to identify usability of the system. Specific components of the system will be addressed in the survey including consistency workflow, ease of use, and ease of input. In addition to this survey, three individuals from each enduser group will be interviewed for qualitative information regarding usability of the design. Both survey and interview evaluation methods are successful in determining usability of system design (Horsky et al., 2010). Computerized Clinical Decision Support The International Patient Decision Aid Standard (short form) (IPDAS) checklist will be utilized to evaluate the CCDS system. This checklist utilizes 12 dimensions to identify the success of the CCDS system. Examples of evaluation components of this tool include (1) balanced presentation options, (2) use of up-to-date evidence, (2) alerts, (4) decision support, (5) and effectiveness. The IPDAS checklist allows users and developers to assess the CCDS system post implementation. The flexibility of this tool also allows certain dimensions to be changed to

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COMPREHENSIVE EXAM determine the appropriateness of the system to the chosen environment. Three end-users from each discipline will utilize this tool to determine delivery outcomes. The IDPAS method will assist in assessing the quality and effectiveness of CCDS system (Elwyn et al., 2009). In addition to evaluating the new technology and design, the INS will work with the quality department to determine success in reducing medical errors and creating a culture of safety. It is essential for the INS to work with other disciplines to abstract and analyze data related to the affects of HIT and assess the need for improvement (ANA, 2010). Tool and data outcomes will then be utilized to make further alterations to HIT as needed. Human Intuition Though HIT has been successful in preventing medical error, humans will be adaptable and continue to work towards obtaining goals (Karsh, Weinger, Abbott, & Wears, 2010). Humans are better at responding to unexpected issues and obstacles than technology. It is essential that a determination be made to forgo technology when immediate outcomes are at risk (Karsh et al., 2010). The context of human decisions should always be considered if undesirable consequences are at stake. If there is immediate harm associated with lack of action, then people must rely on human intuition and gained knowledge to prevent adverse outcomes. The utilization of this human intuition will assist with promoting a culture of safety and avoiding the poor impact on quality of care (Karsh et al., 2010). Conclusion Culture safety through the prevention of medical errors is an important aspect of quality improvement. Organizations and clinicians are also accountable in providing a safe

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COMPREHENSIVE EXAM environment and quality of care (Myers & Shannon, 2012). The INS is responsible for incorporating HIT into the clinical environment (ANA, 2008). It is implied that culture safety and improved quality of care are possible through the reduction of medical errors (Huckvale & Akiyama, 2010). Nursing informatics is incorporated into the nursing setting through appropriate management and adequate communication. The INS should provide adequate direction to assist in this process (ANA, 2008). Through this process, improved quality of care and patient outcomes can be realized with the use of appropriate informatics techniques. EHRs, CCDS systems, and CPOE are all forms of HIT that have been identified to promote safety culture and quality healthcare (Radecki & Sittig, 2011). Though HIT has been defined as an effective strategy to decrease medical error, there are also some concerns associated with its implementation. System design and usability have been found to significantly affect the success of HIT. It has been identified that appropriate change strategies can be implemented to supersede these barriers (Sittig & Singh, 2011). The INS should identify issues with technology and create and effective plan for successful resolution (ANA, 2008). The incorporation of theory to assist with development and implementation of change has been found to be essential. Lewins theory is a frequently utilized in informatics and has been found to be an effective framework for change. In addition, evaluation of outcomes related to the implementation of HIT is crucial to identify the effectiveness to promote culture safety (Stevens et al., 2011). Effective tools are needed to monitor HIT outcomes. The Likert scale, interviews, and the IDPAS checklist are appropriate tools to evaluate HIT quality. However, even in a

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COMPREHENSIVE EXAM technology rich world, it is important to rely on human decisions in the event that imminent consequences are at stake. Through review, it is evident that HIT has the potential to establish a culture of safety and improve quality of care despite concerns related to possible barriers.

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COMPREHENSIVE EXAM References American Nurses Association (ANA) (2008). Nursing Informatics: Scope & Standards of Practice. Silver Spring, MD: Nursesbooks.org Chapman, R. J., Taylor, L., & Wood, S. D. (2012). Cataloging errors from reported informatics patient safety adverse events. Symposium on Human Factors and Ergonomics in Health Care, 87-94. Retrieved from www.hfes.org/ Elwyn, G., OConnor, a. M., Bennett, C., Newcombe, R. G., Politi, M., . . .Edwards, A. (2009). Assessing the quality of decision support technologies using the international patient decision aid standards instrument (IPDAS). PLoS One, 4(3), e4705. doi:10.1371/journal.pone.0004705.t003 Hersh, W. (2009). A stimulus to define informatics and health information technology. BMC Medical Informatics and Decision Making, 9(24), 1-6. doi:10.1186/14726947-9-24 Herzer, K. R., Mirrer, M, Xie, Y., Steppan, J., Li, M., . . . Mark, L. (2012). Patient safety reporting systems: Sustained quality improvement using a multidisciplinary team and good catch awards. The Joint Commission Journal on quality and Patient Safety, 38(8), 339-347. Horsky, J. McColgan, K., pang, J. E., Melnikas, A. J., Linder, J. A., . . . & Middleton, B. (2010). Complementary method of system usability evaluation: Surveys and observations during software design, and development cycles. Journal of Biomedical Informatics, 43(5), 782-790. doi:10.1016/j.jbi.2010.05.010

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COMPREHENSIVE EXAM Huckvale, C., Car, J., & Akiyama, M., Jaafar, S., Khoja, T., . . .& Majeed, A. (2010). Information technology for patient safety. Quality and Safety in Health Care, 19, i25-i33. doi:10.1136/qshc.2009.038497 Jao, C. S., & Hier, D. B. (2010). Clinical decision support systems: An effective pathway to reduce medical errors and improve patient safety. Retrieved from http://cdn.interchopen.com/pdfs Karsh, B., Weinger, M. B., Abbott, P. a., & Wears, R. L. (2010). Health information technology: fallacies and sober realities. Journal of American Medical Informatics Association, 17, 617-623. doi:10.1136/jamia.2010.005637 Kilbridge, P. M., & Classen, D. (2008). The informatics opportunities at the intersection of patient safety and clinical informatics. Journal of the American medical Informatics Association, 15(4), 397-407. doi:10.1197/jamia.M2735 Kutney-Lee, A., & Kelly, D. (2011). The effect of hospital electronic health record adoption on the nurse-assessed quality of care and patient safety. The Journal of Nursing administration, 41(11), 466-472. doi:10.1097/NNA.0b013e3182346e4b Liebovitz, D. (2009). Health care information technology: A cloud around the silver lining? Archives of Internal Medicine, 169(10), 924-926. Manor, P. (2010). CPOE: Strategies for success. Nursing Management, 18-20. Myers, J. S., & Shannon, R. P. (2012). Chasing high performance: Best business practices for using health information technology to advance patient safety. American Journal of Managed Care, 18(4), e121-e125. Retrieved from http://www.ajmc.com/

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COMPREHENSIVE EXAM Radecki, R. P., & Sittig, D. F. (2011). Application of electronic health records to the joint commissions 2011 national patient safety goals. The Journal of the American Medical Association, 306(1), 92-93. doi:10.1001/jama.2011.937 Saleem, J. J., Russ, A. L., Sanderson, P., Johnson, T. R., Zhang, J, Sittig, D. F. (2009). Current challenges and opportunities for better integration of human factors research with development of clinical information systems. IMIA Yearbook of Medical Informatics, 48-57. Saxena, K., Lung, B. R., & Becker, J. R. (2011). Improving patient safety by modifying provider ordering behavior using alerts (CDSS) in CPOE system. AMIA Annual Symposium Proceedings, 1-10. Sittig, D. F., & Singh, H. (2011). Defining health information technology-related errors: New developments since to err is human. Archives of Internal Medicine, 171(14), 1281-1284. Stevens, J. D., Bader, M. K., Michele, L., Johnson, L. M. (2011). Cultivating quality: Implementing standardized reporting and safety checklists. American Journal of Nursing, 5, 48-53. doi:10.1097/01.NAJ.0000398051.07923.69

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