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

376 M. Apkon
medication vial and compare it with the medication order. Throughout the task,
attention was required to ensure that the standard operating procedure was followed
correctly.
The likelihood of error or failure would be reduced if tasks could be eliminated.
One could consider the overall task of replacing the medication cassette. Were the
cassettes to hold a larger volume, the task of replacement would not be required as
frequently which would reduce the likelihood of harm over the course of therapy.
One could also consider the component tasks of the replacement process. If the
task of choosing, whether to wait for the patient’s medication drawer to be refilled
or to override the dispensing machine and choose an alternative mechanism for
dispensing, were eliminated, there would not be an opportunity for error.
The likelihood of error would also be reduced if certain functions could be
replaced. For example, the function of memory could be replaced by information
systems that make the correct dose retrievable at the dispensing machine.
Alternatively, functions could be facilitated so that they would be less error prone.
Electronic calculators are examples of mechanisms to facilitate the action of
performing mathematical operations to reduce the likelihood of mistakes.
Even when errors occur, harm can be prevented by detecting abnormalities
early. In the example of the patient receiving a narcotic infusion, monitoring blood
oxygenation or exhaled carbon dioxide could detect respiratory depression as a
consequence of an overdose before any permanent harm occurs. When abnormalities
are detected and even when they are not, there may be opportunities to mitigate
harm or rescue. In continuing the overdose scenario, respiratory depression could
be reversed using pharmacologic antidotes or a patient may be resuscitated with
mechanical ventilation and supported until the medications are metabolized.
Innovative solutions that reduce error may arise from any number of creative
processes. Seeking solutions that eliminate tasks, replace or facilitate function,
detect abnormalities, or enable rescue provide a useful framework and helps
generate a broad range of countermeasures for consideration.
29.6 High Reliability and Informatics
29.6.1 Information Technology
and Error-Proofing Strategies
Information technology can be incorporated into each of the error-proofing strategies
described above. For example, computerized physician order entry (CPOE)
solutions could be used to eliminate tasks, replace or facilitate actions, improve
detection of abnormalities and help ensure rescue.
Consider the ordering of methotrexate, a potent cancer chemotherapeutic agent
that is administered in doses based on body surface area which is calculated based
on a patient’s height and weight. It is common to monitor serum methotrexate