comp2 unit10a lecture slides

The Culture of HealthcareSociotechnical Aspects:

Clinicians and Technology

This material (Comp2_Unit10a) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number

IU24OC000015.

Lecture a

Sociotechnical Aspects: Clinicians and Technology

Objectives – Lecture a• Describe the concepts of medical error and patient safety (Lecture

a, b)• Discuss error as an individual and as a system problem (Lecture a)• Compare and contrast the interaction and interdependence of social

and technical “resistance to change” (Lecture c)• Discuss the challenges inherent with adapting work processes to

new technology (Lecture c)• Discuss the downside of adapting technology to work practices and

why this is not desirable (Lecture c)• Discuss the impact of changing sociotechnical processes on quality,

efficiency, and safety (Lecture a, b)

2Health IT Workforce Curriculum Version 3.0/Spring 2012

The Culture of Healthcare Sociotechnical Aspects, Clinicians and Technology

Lecture a

Focus Of This Lecture• Medical Errors and Patient Safety• Medical errors: mistakes that occur during

medical care• Patient Safety: reduction in patient harm• Reducing medical errors and improving patient

safety are core aims of modern medicine



Lecture a

Medical Errors• In 1964, one study published in the Annals of

Internal Medicine reported that:– 20% of patients admitted to a university

hospital medical service suffered iatrogenic injury

– 20% of those injuries were serious or fatal• In the U.S., medical errors are estimated to

result in 44,000 to 98,000 unnecessary inpatient deaths annually



Lecture a

Adverse Events• Adverse events occur in all healthcare systems

and in all nations• Data suggests a majority of these events occur

in the hospital setting• Other areas not immune to adverse events



Lecture a

Issues Facing Developing Nations• In developing countries, other significant issues

contribute to errors:– Infrastructure and equipment are inadequate– Drug supply and quality are unreliable– Some healthcare workers may have

insufficient technical skills due to inadequacy of training

– Operating costs are often underfinanced



Lecture a

Types Of Errors• Errors Caused By Individuals:

– Unintended acts of omission or commission– Acts that do not achieve their intended

outcomes • Errors Caused By Systems:

– Complexity of healthcare and healthcare technology

– Complexity of disease and dependence on intricate clinical collaborations and interventions



Lecture a

History Of Error Inquiry• Prior focus of inquiry for errors was on the

individual, and on the mistakes themselves– Investigations often reflected "name and

blame" culture• Now the focus is on the system – fixing

inadequacies in the system can improve patient safety– Focus on system allows individuals to perform

their tasks in a patient-care optimized environment



Lecture a

Individual Errors – Slips

• Some errors or “slips” are unconscious• Usually a “glitch” when performing repetitive,

routine actions• Usually attention is diverted, and there is an

unexpected break in the routine• Attention can be impaired by many factors



Lecture a

Slips – Solving The Problem

• Need to limit opportunities for loss of attention• Example: sleep deprivation during resident

training• Resident training in the US – limit to the number

of duty hours per week to reduce slips due to fatigue and sleep deprivation



Lecture a

Individual Errors – Mistakes

• Some errors or “mistakes” are rule-based or knowledge-based– These are errors of conscious thought

• Rule-based errors -- usually occur during problem-solving when a wrong rule is applied

• Knowledge-based errors – usually occur when the decision-maker confronts a novel solution



Lecture a

Mistakes – Solving The Problem

• Rule-Based Errors– Use clinical decision support – order sets– Avoid bias in clinical reasoning

• Knowledge-Based Errors– Improve knowledge at the point of care– Foster culture of collaboration and

consultation



Lecture a

System Errors

• System errors: these errors occur because of inadequacies within the system

• Often committed by multiple individuals who intersect with patient care

• Often difficult to analyze



Lecture a

Example: Medication Errors

• Unintended changes in medications occur in 33% of patients at the time of transfer from one unit to another within a hospital

• 14% of patients have unintended changes in their medications when they are discharged from the hospital

• More than half of patients have at least 1 unintended medication discrepancy at hospital admission



Lecture a

Medication Reconciliation

• Medication reconciliation: process of avoiding unintended changes in medication across transitions in care

• Requires iterative reviews of patient’s medications at different points of time during the hospital stay



Lecture a

Medication Reconciliation• Methods for medication reconciliation:

– Only pharmacists order medications– Linking process to computerized physician

order entry (CPOE)– Integrating medication reconciliation in the

EHR– Patients reconcile their medications instead of

clinicians• Studies suggest reduction in errors but have not

yet demonstrated improvement in outcomes16Health IT Workforce Curriculum

Version 3.0/Spring 2012


Lecture a

Who is Driving Patient Safety Initiatives?

• Clinicians • Hospitals• Regulatory bodies – for example, the Joint

Commission on Accreditation of Healthcare Organizations

• Patients



Lecture a


Summary– Lecture a

• Focused on medical errors and patient safety• Distinguished slips from mistakes• The concept of system errors • Examined the driving forces championing patient

safety initiatives.



Lecture a


References – Lecture aReferences• Auerbach, A., Landefeld, C., et al. (2007). The tension between needing to improve care and knowing how to do it.

New England Journal of Medicine, 357: 608-613.• Donabedian, A. (1988). The quality of care: how can it be assessed? Journal of the American Medical Association,

260: 1743-1748.• Kohn, L., Corrigan, J., et al., eds. (2000). To Err Is Human: Building a Safer Health System. Washington, DC.

National Academies Press.• Krumholz, H. and Lee, T. (2008). Redefining quality -- implications of recent clinical trials. New England Journal of

Medicine, 358: 2537-2539.• Leape, L. (2000). Institute of Medicine medical error figures are not exaggerated. Journal of the American Medical

Association, 284: 95-97.• McGlynn, E., Asch, S., et al. (2003). The quality of Healthcare delivered to adults in the United States. New

England Journal of Medicine, 348: 2635-2645.• Nolte, E. and McKee, C. (2008). Measuring the health of nations: updating an earlier analysis. Health Affairs, 27:

58-71.• Schimmel EM. The Hazards of Hospitalization. Ann Intern Med January 1, 1964 60:100-110• Sox, H. and Woloshin, S. (2000). How many deaths are due to medical error? Getting the number right. Effective

Clinical Practice, 6: 277-283.• The State of Healthcare Quality: 2009. Washington, DC, National Committee for Quality Assurance.

http://www.ncqa.org/tabid/836/Default.aspx.



Lecture a

http://www.ncqa.org/tabid/836/Default.aspx

comp2 unit10a lecture slides

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