The Essentials of Patient Safety - Clinical Human Factors Group

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The Essentials of Patient Safety anticoagulants, heparin and anti-infective agents and reductions in inappropriate doses and frequency of drugs given to patients with renal insufficiency (11). Evidence of the value of CPOE continues to accumulate. However, many of the systems however remain - numbers of patients in specific settings. Much more research is needed to compare different applications, identify key components, examine factors relating to acceptance and uptake and anticipate and monitor the problems that such systems may induce. Looking further ahead it is possible to envisage the use of many other technologies in the process of medication delivery. Most of these are in the early stages of development, are relatively untested and sometimes delayed by external constraints. Bar coding for instance, widely used in supermarkets, could be enormously useful but cannot be implemented until drug manufacturers have agreed common standards. Considerable advances have been made however in the reliability and efficiency of blood sampling and blood transfusion. KEY POINTS Standardising and simplifying clinical processes is a powerful way of increasing reliability Reducing reliance on human beings with decision support and technology increases reliability in standardised systems Even in good systems people need to anticipate hazards and create safety moment to moment Medication errors can be reduced by preventing error, by making errors more visible and by planned limitation of harm from remaining errors Computerised prescribing reduces medication error but is not a panacea References 1. Berwick DM. Escape Fire. Designs for the future of healthcare. San Francisco: Jossey Bass; 2003. 2. Woods DD, Cook RI. Nine steps to move forward from error. Cognition Technology and Work, 2002;4(2):137-44. 3. Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco Jossey-Bass Publishers; 1996. 4. Darzi A. High Quality Care for All. Department of Health, 2009. 5. Nelson EC, Batalden P, Godfrey MM. Quality by design. A clinical microsystems approach. San Francisco: Jossey Bass; 2007. 6. Bates DW, Gawande AA. Improving Safety with Information Technology. New England Journal of Medicine, 2003;348(25):2526-34. 34
The Essentials of Patient Safety 7. Bates DW. Using information technology to reduce rates of medication errors in hospitals. British Medical Journal, 2000;320(7237):788-91. 8. Haig K, Wills L, Pedersen P, Patterson C, Novario M, Hoy R, et al. Improvement Report: Reducing adverse drug events per 1,000 doses. IHI; 2004 [updated 2004/10/15/]; Available from: http://www.ihi.org/search/pages/results.aspxk=haig%20ADE. 9. Hollingworth W, Devine EB, Hansen RN, Lawless NM, Comstock BA, Wilson-Norton JL, et al. The impact of e-prescribing on prescriber and staff time in ambulatory care clinics: a time motion study. Journal American Medical Informatics Association, 2007;14(6):722-30. 10. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical Association. 1998;280(15):1311-6. 11. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Archives of Internal Medicine, 2003;163(12):1409-16. 35
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