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Lou Agosta

Greetings and welcome to my blog focusing on reengineering healthcare using information technology. The commitment is to provide an engaging mixture of brainstorming, blue sky speculation and business intelligence vision with real world experiences – including those reported by you, the reader-participant – about what works and what doesn't in using healthcare information technology (HIT) to optimize consumer, provider and payer processes in healthcare. Keeping in mind that sometimes a scalpel, not a hammer, is the tool of choice, the approach is to be a stand for new possibilities in the face of entrenched mediocrity, to do so without tilting windmills and to follow the line of least resistance to getting the job done – a healthcare system that works for us all. So let me invite you to HIT me with your best shot at LAgosta@acm.org.

About the author >

Lou Agosta is an independent industry analyst, specializing in data warehousing, data mining and data quality. A former industry analyst at Giga Information Group, Agosta has published extensively on industry trends in data warehousing, business and information technology. He is currently focusing on the challenge of transforming America’s healthcare system using information technology (HIT). He can be reached at LAgosta@acm.org.

Editor's Note: More articles, resources, and events are available in Lou's BeyeNETWORK Expert Channel. Be sure to visit today!

Consider three different scenarios that place healthcare patient safety at risk. The first is an individual hazard, the second human behavior, and the third a system issue in the broad sense of "system" as distinct from information technology (IT).

The first consists in placing concentrated potassium alongside diluted solutions of potassium based electrolytes. Now you need to know that intravenous administration of the former (concentrated potassium) results in stopping the heart almost instantaneously. In one tragic case, for example, an individual provider mistakenly selected a vial of potassium chloride instead of furosemide, both of which were kept on nearby shelves just above the floor. A mental slip-erroneous association of potassium on the label with the potassium-excreting diuretic-likely resulted in the failure to recognize the error until she went back to the pharmacy to document removal of the drug.[1] By then it was too late.  

Second, a pharmacist supervising a technician, working under stress and tight time deadlines due to short staffing, does not notice that the sodium chloride in a chemotherapy solution is not .9% as it should be but is over 23%. After being administered, the patient, a child, experiences a sever headache and thirst, lapses into a coma, and dies. This results in legislation in the state of Ohio called Emily's Law. The supervisor loses his license and is reportedly sentenced to six months in jail.[2]

Finally, in a patient quality assurance session, the psychiatric residents on call at a major  urban teaching hospital dedicated to community service express concern that patients are being forwarded to the psychiatric ward without proper medical (physical) screening. People with psychiatric symptoms can be sick too with life-threatening physical disorders. In most cases, it was 3 AM and the attending physician was either not responsive or dismissive of the issue. In one instance, the patient had a heart rate of 25 (where 80+ would be expected) and a Code had to be declared. The nurses on the psychiatric unit were not allowed to push a mainline insertion into the artery to administer the atropine and the harried resident had to perform the procedure himself. Fortunately, this individual knew what he way doing and likely saved a life. In another case, the patient was delirious and routine neurological exam - made up on the psychiatric unit, not in the emergency room where it ought to have been done - resulted in his being rushed into the operating room to save his life.

In all three cases, training is more than adequate. The delivery of additional training would not have made a difference. The individual knew concentrated potassium was toxic but grabbed the wrong container, the pharmacist knew the proper mixture, and the emergency room knew how to conduct basic physical(neurological)  exams for medical well being. What then is the recommendation?

One timely suggestion is to manage quality and extreme complexity by means of check lists. A checklist of high alert chemicals can be assembled and referenced. Wherever a patient is being delivered a life-saving therapy, sign off on a checklist of steps in preparing the medication can [should] be mandatory. The review of physical status of patients in the emergency room is perhaps the easiest of all to be accommodated, since vital signs and status are readily definable. Note that such an approach should contain a "safe harbor" for the acknowledgment of human and system errors as is routinely performed in the case of failures of airplane safety, including crashes. Otherwise, people will be people are try to hide the problem, making a recurrence  inevitable.

The connection with healthcare information technology (HIT) is now at hand. IT professionals have always been friends of check lists. Computer systems are notoriously complex and often are far from intuitive. Hence, the importance of asking the right questions at the right time in the process of trouble shooting the IT system. Healthcare professionals are also longtime friends of checklists for similar reasons, both by training and experience. Sometimes symptoms loudly proclaim what they are; but often they can be misleading or anomalous. The differential diagnosis separates the amateurs from the veterans. Finally, we arrive at a wide area of agreement between these two professions, eager as they are to find some common ground.

Naturally, a three ring binder on a shelf with hard copy is always a handy backup; however, the computer is a ready made medium for delivering advice, including top ten things to watch in the form of a checklist, in real time to a stressed provider. In this case of emergency room and clinics, the hospital information system (HIS) is the choice platform to install, update, and maintain the checklist electronically. However, this means that the performance of the system needs to be consistent with delivery of the information in real time or near real time mode. It also means that the provider should be trained in the expert fast path to the information and need to hunt and peck through too many screens. The latter, of course, would be equivalent to not having a functioning list at all.

And this is where a dose of training in information technology will make a difference. The prognosis is especially favorable if the staff already have a friendly - or at least accepting - relationship with the HIS. It reduces paper work, improves workflow, and allows information sharing to coordinate care of patients.

This is also a rich area for further development and growth as system provide support to the physician in making sure all of the options have been checked. The system does not replace the doctor, but acts like a co-pilot or navigator to perform computationally intense tasks that would otherwise take too much time in situations of high stress and time pressure. Obviously issues of high performance response on the part of the IT system and usability (from the perspective of the professionals staff) loom large here. Look forward to further discussion on these points. Meanwhile, we now add another item to add to the vendor selection checklist in choosing a HIS: must be able to provide templates (and where applicable, content) for clinical checklists by subject matter area.

It should be noted that "the checklist manifesto" is the recommendation in a book of the same title by the celebrity physician, Atul Gawande, MD, who is also the author of an engaging column in the New Yorker on all manner of things medical and a celebrity since being quoted by President Obama in the healthcare debate. However, make no mistake. The checklist is not a silver bullet. By all means, marshal checklists and use them to advantage. Still, there are some scenarios where long training, experience, a steady hand, and concentration are indispensable. In flight school, take off and landing checklists are essential. This is the normal checklist. Non-normal checklists are also available on how to restart your engines from 30,000 feet. But a double bird strike on take-off at 5000 feet, disabling both engines, is not on anyone's list. You cannot even get the binder down off the shelf in the amount of available time, the latter generally being the critical variable in short supply. Then there is no substitute for experience, leavened with a certain grace.  But for the rest of us humans, and in the meantime, assemble, update, and use your checklists.



[1] "Potassium may no longer be stocked on patient care units, but serious threats still exist"  Oct 4 2007, http://www.ismp.org/newsletters/acutecare/articles/20071004.asp

[2] "An Injustice has been done," http://www.ismp.org/pressroom/injustice-jailtime-for-pharmacist.asp


Posted August 16, 2010 1:08 PM
Permalink | 1 Comment |

1 Comment

The concept of checklists in healthcare is both intriguing and scary. Any clinical, technical or operational improvement which improves both patient safety and the quality of care, with a nominal impact to the efficiency of care should be further explored. Checklists provide opportunities to reduce the number of medical errors that occur. However, identifying where, when and how checklists could be implemented, integrated, supported and utilized is the largest piece of the puzzle. I can envision seamless real-time integration of checklist results entered via handheld PDA's and laptops with hospital information systems. And I can also envision situations where checklists need to incorporate interactive decision support metrics and actionable information via business intelligence applications; allowing physicians, nurses, etc. to provide care based both upon required checklists and on real-time outcomes data. For example, the administration of medications within a hospital is a focus area of high importance for patient safety personnel and it involves managing numerous variables (medication, dosage, form and drug interactions). Balancing these types of tasks with outcomes data reported via business intelligence applications will require healthcare personnel to both be flexible and cognizant that there will at times be situations where the checklist serves as a guideline and not a playbook.

Tom Callahan
Product Manager, Healthcare Solutions
Datawatch

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