Working with Health IT Systems HIT Facilitated Error

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 IU 24 OC 00013. This material was updated by The University of Texas Health Science Center at Houston under Award Number 90 WT 0006. This work is licensed under the Creative Commons Attribution-Non. Commercial-Share. Alike 4. 0 International License. To view a copy of this license, visit http: //creativecommons. org/licenses/by-nc-sa/4. 0/.

HIT Facilitated Error—Cause 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 Twins—Movie (CNN, 2010) https: //www. youtube. com/watch? v=XEbf 9 bli. Ous (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 (Cont’d – 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/PMC 353015/ 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=XEbf 9 bli. Ous 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/Med. Watch/Safety. Information/Safety. Alertsfor. Human. Medical Products/UCM 154539. 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-heparinrecall. 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 IU 24 OC 00013. This material was updated by The University of Texas Health Science Center at Houston under Award Number 90 WT 0006. 9