Presentation
“I am sorry, your mother is not actually dead”: Wrong chart admissions and their impact on healthcare safety and experience
DescriptionHealthcare has made significant strides in accurate patient identification through the focus brought to this issue via National Patient Safety Goals. One area where our health system has experienced continued concerns is in the unique scenario of patients who are admitted into another person’s existing medical record. This session would explore the contributing factors to these errors, challenges to past improvement work, and key aspects to developing a more resilient process.
From the beginning of this project, a broad scope of contributing factors were identified, from technical challenges, to community relationships, to time pressures. While this project initially aimed to address a very narrow issue, it has evolved with an expanded scope to not only address error prevention, but also error mitigation and resolution- all with significant system constraints. In addition to specific guidance on the topic of wrong chart admissions, the project provides case examples of approaches to common concerns of IT integration and interoperability, as well as approaching complex nested systems in healthcare. Ensuring that care is provided as quickly as possible, key information is available to clinicians when they need it, ensuring records are accurate, and quickly redirecting downstream processes that are automatically set in motion upon patient arrival is not easily done.
Through several interwoven anecdotes illustrating the impact of incorrect chart admissions, the audience will be provided with thought provoking examples of how a broad network of stakeholders can come together to establish a more resilient process that takes into account the difficult tradeoffs while ensuring safe care and a compassionate experience.
By illustrating the details of complex nested work systems including technologies with limited interoperability, the presentation would demonstrate how small errors in a rigid system can quickly become exacerbated by snowballing downstream effects. These downstream effects can quickly lead to immeasurable physical and emotional harm for patients and their families, as well as abundant non-value added work for support teams. This session would walk audiences through how the team, when lead by a human factors engineer, was able to establish a more resilient process that takes into account difficult tradeoffs while keeping the safety and dignity of our patients and families at the center of our work.
Take away points:
• A healthcare environment’s technology is only as good as its flexibility and interoperability.
• Non-patient facing support services cannot be overlooked in patient safety and experience due to the nature of healthcare’s nested work systems.
• Concurrently designing systems to jointly optimize patient safety, experience, and staff efficiency is essential to implementing lasting change.
From the beginning of this project, a broad scope of contributing factors were identified, from technical challenges, to community relationships, to time pressures. While this project initially aimed to address a very narrow issue, it has evolved with an expanded scope to not only address error prevention, but also error mitigation and resolution- all with significant system constraints. In addition to specific guidance on the topic of wrong chart admissions, the project provides case examples of approaches to common concerns of IT integration and interoperability, as well as approaching complex nested systems in healthcare. Ensuring that care is provided as quickly as possible, key information is available to clinicians when they need it, ensuring records are accurate, and quickly redirecting downstream processes that are automatically set in motion upon patient arrival is not easily done.
Through several interwoven anecdotes illustrating the impact of incorrect chart admissions, the audience will be provided with thought provoking examples of how a broad network of stakeholders can come together to establish a more resilient process that takes into account the difficult tradeoffs while ensuring safe care and a compassionate experience.
By illustrating the details of complex nested work systems including technologies with limited interoperability, the presentation would demonstrate how small errors in a rigid system can quickly become exacerbated by snowballing downstream effects. These downstream effects can quickly lead to immeasurable physical and emotional harm for patients and their families, as well as abundant non-value added work for support teams. This session would walk audiences through how the team, when lead by a human factors engineer, was able to establish a more resilient process that takes into account difficult tradeoffs while keeping the safety and dignity of our patients and families at the center of our work.
Take away points:
• A healthcare environment’s technology is only as good as its flexibility and interoperability.
• Non-patient facing support services cannot be overlooked in patient safety and experience due to the nature of healthcare’s nested work systems.
• Concurrently designing systems to jointly optimize patient safety, experience, and staff efficiency is essential to implementing lasting change.
Event Type
Oral Presentations
TimeMonday, March 251:50pm - 2:10pm CDT
LocationSalon A-1
Hospital Environments