Archive for March, 2013|Monthly archive page

Luck of the Irish or workflow?

In Behavior change, culture, user experience on March 17, 2013 at 9:27 am

According to the Office of the National Coordinator (ONC), 30% of all Health IT implementations fail. What causes failure? A workforce that doesnt want to change? Poor technology? Luck?
It’s unlikely to be any of these things. It is usually the inattention to workflow and culture that leads to failure of Health IT initiatives designed to improve patient safety.
What do hosptial IT execs know about the culture of their institutions? Probably not much. Aminstrators in general have different opinions of safety culture than front line staff (the latter see less safety). How often do we do post IT implementation and periodic surveys to see if workflow is indeed more “flowing” than bottlenecked? My guess is not very often or we would see these survey results at the top of every Health IT companies webpage. Most products now are only rated by IT execs through a propriatary report. We need a marketplace website for all thse like Amazon where end users can rate and evaluate the products!!

Read the chapter from Patient Safety and Quality for Nurses from the NIH
about workflow.
Cain C, Haque S. Organizational Workflow and Its Impact on Work Quality. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 31. Available from:

Need an interpreter for research data?

In Patient Safety on March 8, 2013 at 7:37 pm

On the pages of this blog I often post references so that you can read the articles for yourself and make your own decisions.

This is a great article about hypothesis and p values to help you make sense of results and whether the hypothesis testing is significant


In Patient Safety on March 8, 2013 at 7:03 pm

A cool blog I stumbled upon related to Patient safety:
the community of medical packaging experts

We definately need packaging standards. This isnt about marketing profucts, its about safety.
Read through some blog posts for a different perspective.

RCA on Root Cause Analysis

In Force function, ismp, Root cause analysis on March 2, 2013 at 11:55 pm

flowerRCA (root cause analysis) is a tool often used to provide an assessment after the occurrence of an adverse event or when investigating the safety of an environment. The idea behind this risk assessment is to uncover the overt and latent factors behind unsafe situations.  In non-medical industries this has proven to be an effective tool but in healthcare, the belief that this tool helps is variable. While many RCAs have uncovered surprising holes in healthcare safety systems, there are also concerns with its value.

In a 2008 interview with Robert Watcher, Albert Wu  said “Although we are living in an era of evidence-based medicine, root cause analysis was widely adopted by the medical community in the 1990s without the benefit of much evidence. Every institution now conducts root cause analysis. Thousands of health care workers devote many hours to conducting these analyses, yet root cause analysis has never really been evaluated.” (AHRQ,

Some of the barriers to conducting root cause analysis:
(read the rest of this post) Read the rest of this entry »

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