Presentation
PS2 - A SEIPS 101 Analysis of Heparin Administration in Inpatient Care Settings
DescriptionHeparin is an important medication for treating several conditions but it must be carefully administered: receiving too much or too little puts patients at risk of adverse events. A large healthcare system identified the six most common heparin administration errors across its 18 hospitals, and asked an HFE team to help identify the factors that contribute to those errors. The HFE team visited one suburban and two urban hospitals, where they observed heparin administration and interviewed nursing staff to gain better understanding how and why the most common errors manifest and to obtain feedback on potential changes to the electronic medical record (EMR) and the heparin protocol that could help reduce the risk of specific errors. The team identified many factors that contribute to heparin administration errors including training inconsistencies, staff being required to remember calculated rates as they travel from the hall where EMR is accessed to the patient bedside where pumps are programmed, and confusion regarding patient weight (medication order weight versus actual weight). The most significant factor, though, was poor usability of several parts of the EMR.
The HFE team used data from observations and interviews notes to create a SEIPS tools-task matrix (Holden & Carayon, 2021), which provides insight to the interplay between staff members and the technology they need to use to perform the task of heparin administration. This data also informed the HFE team’s recommendations for improvement: for example, some RNs were concerned about some of the potential opportunities for automation, pointing out it might reduce “critical thinking” needed to provide optimal patient care. Recommendations to help reduce errors were grouped into four categories: potential EMR changes; potential nurse-driven heparin protocol changes; nudges and reminders to order PTT draws, to draw blood and send to the lab, and to check for PTT results; and suggestions to help improve RN heparin administration training.
The HFE team used data from observations and interviews notes to create a SEIPS tools-task matrix (Holden & Carayon, 2021), which provides insight to the interplay between staff members and the technology they need to use to perform the task of heparin administration. This data also informed the HFE team’s recommendations for improvement: for example, some RNs were concerned about some of the potential opportunities for automation, pointing out it might reduce “critical thinking” needed to provide optimal patient care. Recommendations to help reduce errors were grouped into four categories: potential EMR changes; potential nurse-driven heparin protocol changes; nudges and reminders to order PTT draws, to draw blood and send to the lab, and to check for PTT results; and suggestions to help improve RN heparin administration training.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives