HIT Facilitated Error Causes in Healthcare Systems
Explore the concept of facilitated errors in Health Information Technology (HIT) systems, delving into scenarios where HIT systems may amplify user errors. Learn about potential causes such as high stress, cognitive limitations, unclear directions, and more, emphasizing the importance of addressing these issues for improved patient safety.
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Working with Health IT Systems HIT Facilitated Error Cause and Effect Lecture a This material (Comp 7 Unit 6) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC00013. This material was updated by The University of Texas Health Science Center at Houston under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
HIT Facilitated ErrorCause and Effect Learning Objectives Lecture a Explain the concept of facilitated error in HIT Cite examples of situations where HIT systems could increase the potential for user error 2
Error in Healthcare Image Courtesy of Dr. Patricia Abbott 3
The Quaid TwinsMovie (CNN, 2010) https://www.youtube.com/watch?v=XEbf9bliOus (Baxter Healthcare Corporation, 2007) 4
Error in Healthcare High stress distraction - busy Cognitive limitations Stuck in thinking Unclear directions Unclear labeling/Poor layout Juxtaposition I was ordering Cortisporin, and Cortisporin solution and suspension comes up. The patient was talking to me, I accidentally put down solution, realized that s not what I wanted . . . I would not have made that mistake, or potential mistake, if I had been writing it out because I would have put down what I wanted. (Ash, Berg, Coiera, 2004) (Akre, 2008) 5
Error in Healthcare (Contd 1) Role change / communication change /workflow change Undue trust? Currency & appropriateness Alert fatigue System rigidity Chow, 2007, CC-BY-NC-SA 2.0 6
Unit 6: HIT Facilitated Error Cause and Effect Summary Lecture a Error causation in healthcare High Stress Distraction; Cognitive Limitations; Stuck in Thinking; Unclear Directions; Unclear Labeling/Poor Layout Role Change/Communication Change/Workflow Change; Undue Trust; Currency & Appropriateness; Alert Fatigue & System Rigidity 7
HIT Facilitated Error Cause and Effect References Lecture a References Ash J., Berg, M., Coiera, E. Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors. 2004. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC353015/ Images Slide 3: Nurse Checking a Man's Blood Pressure. Courtesy Dr. Patricia Abbott Slide 4: CNN,. (2010). Medical error and the Quaid twins. Retrieved from https://www.youtube.com/watch?v=XEbf9bliOus Slide 4: Baxter Healthcare Corporation,. (2007). BAXTER HEPARIN SODIUM INJECTION 10,000 UNITS/ML AND HEP-LOCK U/P 10 UNITS/ML. Retrieved from http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedical Products/UCM154539.pdf Slide 5: Akre, J. (2008). More Deaths Reported as Baxter Expands Heparin Recall.News.legalexaminer.com. Retrieved 13 June 2016, from http://news.legalexaminer.com/more-deaths-reported-as-baxter-expands-heparin- recall.aspx?googleid=29868 Slide 6: Chow, T. (2007). Woman Looking at Man Suspiciously. [Online Image].Retrieved June 13, 2016 from http://www.flickr.com/photos/trevin/2063746097/ 8
Working with Health IT Systems HIT Facilitated Error Cause and Effect Lecture a This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC00013. This material was updated by The University of Texas Health Science Center at Houston under Award Number 90WT0006. 9
