Using Innovative Technologies to Set New Safety Standards for the Infusion of Intravenous Medications

2002 ◽  
Vol 37 (11) ◽  
pp. 1179-1189 ◽  
Author(s):  
James A. Eskew ◽  
Judith Jacobi ◽  
William F. Buss ◽  
Heather M. Warhurst ◽  
Cynthia L. Debord
Keyword(s):  
Health Care ◽  
Health Care System ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Current Control ◽  
Safety System ◽  
Data Set ◽  
Specific Patient ◽  
Infusion Devices ◽  
Care System

Intravenous (IV) administration errors present a particularly challenging problem to hospital pharmacists. Current control systems intercept only 2% of drug administration errors causing preventable adverse drug events (PADEs).4 Estimated costs per preventable ADE are $4685 (1993 dollars). Of the most serious, life-threatening errors, 60% are associated with IV therapy. Conventional, general-purpose infusion devices cannot limit doses or easily be customized for specific patient populations. Clarian Health Partners, a 1400-bed health care system, consolidated infusion devices at three hospitals by implementing the MEDLEY Medication Safety System with Guardrails Safety Software. This new technology offers an innovative IV medication safety platform that functions at the point of care. Clarian became the first U.S. health care system to use this system on a hospital-wide basis. Development of a customized data set based on Clarian's best-practice guidelines was completed in 60 days, and installation at the 775-bed Methodist Hospital was completed in 3 hours. A potentially serious error was averted on the first day of system use. Initial data indicate that use of the IV medication safety system at Clarian's three hospitals will result in 4,000 events of reprogramming annually due to Guardrails alerts.

scholarly journals Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy (Preprint)

2020 ◽  
Author(s):  
Andrew Baumgartner ◽  
Taylor Kunkes ◽  
Collin M Clark ◽  
Laura A Brady ◽  
Scott V Monte ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Human Factors ◽  
Health Care System ◽  
Management System ◽  
Medication Safety ◽  
Medication Management ◽  
Potentially Inappropriate Medications ◽  
Primary Care Office ◽  
Care System

BACKGROUND Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. OBJECTIVE This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. METHODS The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. RESULTS This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. CONCLUSIONS Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

scholarly journals Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy

10.2196/18103 ◽  
2020 ◽  
Vol 7 (3) ◽  
pp. e18103
Author(s):  
Andrew Baumgartner ◽  
Taylor Kunkes ◽  
Collin M Clark ◽  
Laura A Brady ◽  
Scott V Monte ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Human Factors ◽  
Health Care System ◽  
Management System ◽  
Medication Safety ◽  
Medication Management ◽  
Potentially Inappropriate Medications ◽  
Primary Care Office ◽  
Care System

Background Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

Teletinnitus Program at the VA Gulf Coast Veterans Health Care System

2014 ◽  
Vol 4 (1) ◽  
pp. 23-29
Author(s):  
Constance Hilory Tomberlin
Keyword(s):  
Health Care ◽  
Patient Satisfaction ◽  
Patient Care ◽  
Health Care System ◽  
Gulf Coast ◽  
New Technology ◽  
Cost Effective ◽  
Veterans Health ◽  
Potential Benefits ◽  
Care System

There are a multitude of reasons that a teletinnitus program can be beneficial, not only to the patients, but also within the hospital and audiology department. The ability to use technology for the purpose of tinnitus management allows for improved appointment access for all patients, especially those who live at a distance, has been shown to be more cost effective when the patients travel is otherwise monetarily compensated, and allows for multiple patient's to be seen in the same time slots, allowing for greater access to the clinic for the patients wishing to be seen in-house. There is also the patient's excitement in being part of a new technology-based program. The Gulf Coast Veterans Health Care System (GCVHCS) saw the potential benefits of incorporating a teletinnitus program and began implementation in 2013. There were a few hurdles to work through during the beginning organizational process and the initial execution of the program. Since the establishment of the Teletinnitus program, the GCVHCS has seen an enhancement in patient care, reduction in travel compensation, improvement in clinic utilization, clinic availability, the genuine excitement of the use of a new healthcare media amongst staff and patients, and overall patient satisfaction.

What is the best way to reform the U.S. health care system?

2007 ◽  
Vol 38 (1) ◽  
pp. 18
Author(s):  
KEVIN GRUMBACH ◽  
ROBERT MOFFIT
Keyword(s):  
Health Care ◽  
Health Care System ◽  
The U.S ◽  
Care System

What is the best way to reform the U.S. health care system?

2007 ◽  
Vol 40 (1) ◽  
pp. 6
Author(s):  
KEVIN GRUMBACH ◽  
ROBERT MOFFIT
Keyword(s):  
Health Care ◽  
Health Care System ◽  
The U.S ◽  
Care System
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