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

84 W.H. Drummond et al.
A recovery room implementation of an IT system may unexpectedly slow down
transfer processes. Consequently, the number of cases admitted from the operating
room may exceed the number of unoccupied beds in the recovery room, resulting
in canceled surgeries and dissatisfied patients and providers.
Change may interrupt the healthcare process at multiple levels, requiring analysis,
subsequent modifications and interventions to respond to the interruptions. Change
(especially IT implementation) can make existing latent failures of the care system
more pronounced, because previously established work-arounds no longer function.
One example is the implementation of a CPOE system in a hospital where the admission,
discharge, and transfer (ADT) process is not working effectively. Previously, providers
were able to order on paper, even if the patient’s medical record number was not
yet available. With CPOE system, the patient must be registered and must “be in the
system” in order for a provider to place an order. The work-around (the piece of ordering
paper) has effectively been rendered useless without being replaced by another
“break-the-glass functionality” for quick interventions in critically ill patients.
IT implementations in health care venues can fail on many levels. 4–7 In “worst
case” scenarios, poorly designed or implemented IT systems may impact an entire
healthcare system and may lead to a removal of the HIT system, as occurred at
Cedars-Sinai Hospital. 4, 8–10 In health care, unanticipated consequences may not
only have a negative effect on the institution and the providers, but may be dangerous
and detrimental to the health of patients. 11–13
8.2 Scenario A: Change and Consequences
Summary: This case study explores the failure of a quality improvement (QI) initiative
in a neonatal critical care unit. The scenario highlights how important human factor
analysis is to the success of every change process involving human systems, while
illustrating how HIT may sometimes become an obstacle to optimum patient care.
8.2.1 Quality Improvement Goal: Achieving Optimal
Oxygen Saturation
Newborn Intensive Care units (NICU) struggle with managing the oxygen saturation
of premature infants in an optimal range. Too much oxygen may cause blindness;
too little causes brain injury. In this scenario, two NICUs within the same
health system implemented a QI protocol to improve oxygen management in premature
infants that had been successfully used in other institutions (Fig. 8.1).
Nurses set the oxygen alarm limits on the patient’s monitor as per physician
order. The percent of time that the oxygen saturation limits were set as ordered
during random audits was selected as outcome measure. In the first 3 months, the
intervention failed completely in NICU B, while NICU A could show some moderate
success (Fig. 8.2).