Pediatric Informatics: Computer Applications in Child Health (Health ...

88 W.H. Drummond et al.
8.2.2.1 System Change
In the NICU scenario, a failure mode or root cause analysis 16 conducted by the
team implementing the oxygen saturation management protocol revealed that the
failure in NICU B was multifactorial. The finding was not unexpected: In complex
environments such as a NICU, failures usually can be attributed to a number of
individual problems.
Failure could not be blamed on a single group of people or a single process but
responsibility was distributed throughout people, work flows, beliefs, conflicting
interests, IT systems and physical design solutions.
Several factors contributing to failure were beyond anybody’s control (such as
existing wall structures). However, the many factors identified made this problem a
“target-rich” human factors engineering situation. A multifaceted “system change,”
which focused on several of the identified problems, resulted an immediate consensus
for action on many variables.
The problem was split into multiple tasks assigned to different people in order to
address the list of contributing factors, simultaneously. The oxygen saturation management
protocol was suspended in September 2006 to allow revisions, educational
efforts, and involvement of staff nurses in focus groups. When the protocol was
reintroduced in October 2006 after most of the failure causes had been addressed,
improvement in NICU B compliance with resetting the monitor alarms occurred
(Fig. 8.2).
8.2.3 Root Cause Analysis
While this book is focused on health information systems in pediatrics, many of
the failures in implementing these systems – and the root cause of problems in
these scenarios – can be traced to poor Human Factors Engineering. To make this
point, we selected a scenario that had HIT systems as a minor variable. (Note,
that in Scenario A the only HIT systems were the oxygen saturation monitor and
the respiratory care department charting system) to emphasize the complexity of
the environment, the important role that work flow, beliefs, conflicting interests,
complexity of care and physical layout may play. Medicine is already complex
and difficult to navigate – introducing an HIT system to this mix will raise the
complexity dramatically.
The root causes of the failure of our oxygen saturation management protocol
were multifactorial:
Increased workload (increased number of alarms requiring checking and protocol
based responses)
Physical layout (Verification of alarms from a different cubicle in NICU B)
Conflicting tasks (RT charting workflow)
Beliefs (Lack of protocol buy-in related to the deeply ingrained belief of many
nurses and physicians that a pink baby is good)