Archive for September, 2011|Monthly archive page

Articles Nurses may Never read…

In High Reliability Orgs, Human Factors, Interuptions, Patient Safety on September 25, 2011 at 4:39 pm

The Journal of Experimental Psychology: Applied just released a special issue on “Cognitive Factors in Healthcare.”
In the introductory article Morrow and Durso (2011) report that while progress has been made in the human factors front related to patient safety, problems are likely to increase in the future due to: the aging of society, The Affordable care act which will put more patients into the system, and the adoption of technology that can assist safety but often increases the complexity of providing care especially when it is not consistent with clinician needs, goals and practices. One of the challenges to research in the healthcare safety arena is the inability to manipulate variables when there can be such real consequences (Morrow & Durso, 2011). Theories applicable to aviation which is more structured and engineered don’t always translate well into healthcare which is considered to be more of a socio-natural system (Morrow & Durso, 2011). My full review continues here…

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In human error, Patient Safety, Safety climate on September 25, 2011 at 8:00 am

Hand Hygiene?
Yes, but so much more. Please view this graphic entitled “Hospital Hazards” at Mark Graban’s Lean blog.

Some highlights:
“You are 33,000 times more likely to die from a hospital error than from a plane crash.”
“Mistakes in hospitals cost the US $17 billion each year.”
“Fifty percent of Doctors neckties have been found to harbor dangerous pathogens.”

Can’t we fix this?

Mobile Persuation: the future of patient safety?

In Human Factors, Resiliency on September 24, 2011 at 6:56 pm

Many experts believe mobile phones are the future of societal behavior change (Fogg & Eckles, 2007). They are light and full of features and the wireless networks on which they run rival speeds of wired high speed systems. The best feature of mobile phones that contribute to persuasive behavior change is their ability to relay information, make that information actionable and maintain links to social networks. The social connection is where the real magic happens (Fogg & Eckles, 2007). From a mobile platform one could conceivably fall in love, start a revolution, read a life changing book or find a treasure.

In terms of patient safety, I see the ability to act on information as well as the social interaction to hold the most promise. Abnormal labs are sent to an MD who can click on them which takes him to an order set designed for treating the anomalies. This relays to a nurse who carries out the treatment and is beeped if any of the patients vital signs are compromised or even if the patient calls to report a symptom. A nurse could see what the patient ordered for a meal and put a hold on it if it contained too much potassium for example.
With gps and bluetooth, healthcare providers can be tracked on handwashing performance or prompted to wash when they pass a pump. A provider who cant come to a bedside could chat in real time with words and video.
Phones can already scan product barcodes and this technology could enable healthcare providers to have all patient information with them wherever they went.

It’s time to throw out those one way pagers and switch to interactive technology. Pagers function well in a hierarchical system, however if relational coordination is a safety goal, the technology has to facilitate relationships and action.

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