Health Informatics, Patient Safety

BACKGROUND: Fishbone diagrams have been widely promoted as a systems-focused hazard analysis tool for use in root cause analysis, but they suffer from a number of structural weaknesses, including a unidirectional structure that only takes into account forces that promote an accident (ignoring those that make the accident less likely or less severe) and a means of displaying these forces that does not convey any difference in strength of influence. In a separate but related issue, many healthcare organizations suffer from a lack of change management expertise.

PROPOSED SOLUTION: To address these concerns, I present a novel technique, the Lovebug diagram, which draws from both Fishbone diagrams and force-field analysis (an approach to analyzing planned change). This new technique adds value to both its progenitor methods, while retaining their key strengths and ease of use. It can be used both prospectively, to assess planned changes, and retrospectively to assess unplanned (accidental) departures from the status quo.

DISCUSSION: The Lovebug diagram is a more powerful analytical tool than its progenitor methods; however, overall adoption of systems-focused tools for root cause analysis remains suboptimal. Additional research is needed to determine how best to promote a truly systems-focused approach to healthcare root cause analysis. Beyond this retrospective use of the technique, it represents a simple tool to assist healthcare organizations with prospective change management.

Available from: http://cri.sagepub.com/content/early/2013/10/25/1356262213510855.abstract

The Institute of Medicine (IOM) views Health Information Technology (HIT) as an essential organizational prerequisite for the delivery of safe, reliable, and cost effective health services. However, HIT presents the proverbial double-edged sword in generating solutions to improve system performance while facilitating the genesis of novel iatrogenic problems. Incongruent organizational processes give rise to technological iatrogenesis or the unintended consequences to system integrity and the resulting organizational outcomes potentiated by incongruent organizational–technological interfaces. HIT is a disruptive innovation for health services organizations but remains an overlooked organizational development (OD) concern.

Recognizing the technology–organizational misalignments that result from HIT adoption is important for leaders seeking to eliminate sources of system instability. The Health Information Technology Iatrogenesis Model (HITIM) provides leaders with a conceptual framework from which to consider HIT as an instrument for organizational development. Complexity and Diffusion of Innovation theories support the framework that suggests each HIT adoption functions as a technological change agent. As such, leaders need to provide operational oversight to managers undertaking system change via HIT implementation. Traditional risk management tools, such as Failure Mode Effect Analysis and Root Cause Analysis, provide proactive pre- and post-implementation appraisals to verify system stability and to enhance system reliability. Reconsidering the use of these tools within the context of a new framework offers leaders guidance when adopting HIT to achieve performance improvement and better outcomes.

KEYWORDS: Healthcare, health information technology, planning, error, iatrogenesis, risk management, failure mode effect analysis, root cause analysis, diffusion of innovation theory, rogers, complexity theory, complex adaptive systems, organizational development, patient safety, change management, human factors, ivan illich, medical nemesis.

World Health Organization (WHO) set up five priority patient safety issues that needed to be tackled and with participation of  8 countries attempted to create standard operating procedures (SOPs) for promoting patient safety in these issues. This study highlights these "High 5s" of patient safety with additional perspectives as applicable to Indian subcontinent. (This is pdf version of the keynote presentation by Dr. Akilesh Ramasamy at the Patient Safety & Infection Control Conference, held at Holiday Inn, Mumbai on 13 - 14 Dec. 2014)

This study intended to explore the development of health information
technology  and  its  effect  on  decreasing  the  medication  errors  and
protecting  the  patient's  safety.  This  study  which  was  descriptivecomparative  in  nature  has  been  conducted  in  2013  in order  to
examine  the  development  process  of  technology  in  the  healthcare
system  and  its  advantages  for  decreasing  the  medication  errors  and
maintaining  the  patient  safety.  The  data  were  gathered  by  using
different  informational  resources  such  as  valid  articles,  books,
magazines  and  web  sites.  To  compare  and  analyze  different
technology  systems  in  terms  of  developing  and  improving  medical
services delivered by the respective providers, thevaried strategies in
use  in  the  selected  countries  were  gathered  by  studying  a  large
number of articles extracted from numerous scientific magazines and
resources  so  that  an  appropriate  strategy  may  be  proposed  for  the
healthcare  system  of  Iran.  As  the  findings  of  the  study  indicated,
some  information  technologies  including  CPOE,  Bar  code,  AMDS,
PDA,  etc  improved  the  medication  safety  decreasing  the  rate  of
medication  errors  remarkably.  The  obtained  rates  for  such
improvement  in  terms  of  the  type  of  the  error  were  as  follows:
75.47%  for  prescription  errors,  70.34%  for  the  errors  due  to  the
prescribed  medications  listed  for  the  patient  use,  87.41%  for
administration time errors, 93.48% for the  errors resulting  from the
patient's  mistakes.  Accordingly,  to  ensure  the  high performance  of the  informational  systems,  due  attention  must  be  paid  to  their
infrastructures.  Furthermore,  besides  strengthening the  previous
infrastructures, it is necessary to create new onesso as to guarantee
the usability of such systems for the hospitals.

While online survey systems facilitate the collection on copious records on diet, exercise and other health-related data, scientists and other public health experts typically must download data from those systems into external tools for conducting statistical analyses. A more convenient approach would enable researchers to perform analyses online, without the need to coordinate additional analysis tools. This paper presents a system illustrating such an approach, using as a testbed the WAVE project, which is a 5-year childhood obesity prevention initiative being conducted at Oregon State University by health scientists utilizing a web application called WavePipe. This web application has enabled health scientists to create studies, enrol subjects, collect physical activity data, and collect nutritional data through online surveys. This paper presents a new subsystem that enables health scientists to analyse and visualize nutritional profiles based on large quantities of 24-hour dietary recall records for subgroups of study subjects over any desired period of time. In addition, the subsystem enables scientists to enter new food information from food composition databases to build a comprehensive food profile. Interview feedback from novice health science researchers using the new functionality indicated that it provided a usable interface and generated high receptiveness to using the system in practice.