Presentation
HE11 - Nurse Experience Journey Map Based on Infusion Pump
DescriptionInfusion pump is a device used to continuously administer small amounts of medication to patients and is the most owned and used medical device in hospitals. There are many advantages of using infusion pump such as being able to stably control the administration of drugs directly into the body, but errors can lead to patient safety related incidents.
Examples of patient safety incidents due to infusion pump errors include rapid injection due to use errors. There was a case where a patient arbitrarily removed the infusion pump and rapidly injected the medication that was connected to the pump, complaining of chest pain and breathing difficulties. In addition, there was a case where a patient who was injecting ketamine mixed intravenous fluids using infusion pump removed the pump without locking the clamp before MRI, and the medication was rapidly injected, causing consciousness change. These two examples were initiated by patients, but could have been prevented if precautionary measures were taken by the nurses.
The goal is to analyze the occurrence, cause, and solution of patient safety incidents that can occur within medical environments while using infusion pumps and organize the following process into a user experience journey map from a nurse’s point of view.
In order to understand the use of the infusion pump within the use environment, an interview was conducted with nurses working in two different wards in the hospital. Two nurses per ward were interviewed with 26 questions corresponding to three categories: medical environment, infusion pump use environment, and infusion pump use. After the interview, the collected records were systematically transcribed, coded, and grouped by category through thematic analysis. A nurse's experience journey map was created based on categories developed through coding, following the format of a patient journey map and tailored to the workflow of nurses using infusion pumps. The journey map is organized as follows: phase, sub-phase, event, touchpoint, themes and actions, emotions, experience and pain point, Picker's 8 principles, design challenge. “Event” category indicates medical device-related incidents that may occur in “phase” and “sub-phase” categories.
A new nurse persona, who is not familiar working with an infusion pump within the medical environment, was established to systematically classify possible incidents related to the infusion pump during a day shift. There are six representative tasks for nurses: patient identification, patient handover, rounding, regular medication administration, implementation of patient examination and surgery schedules. Infusion pump-related incidents that may occur during these tasks include intravenous fluids replacement errors, medical device alarms, near-miss incident with a medical device drop, and infusion rate errors. When these errors occur, the persona often experiences confusion and fear, which leads to stress and burden on their work. During the study, it was confirmed that improvements, such as enhancing the visibility of infusion pump settings, are necessary to prevent patient safety incidents related to infusion pumps and alleviate unexpected nurse workload. Various incidents that can occur within a nurse’s workflow were organized to analyze the cause of those incidents. In this study, factors related to the use of medical device were used to analyze what types of incidents can occur when met with certain factors and how those factors can be further considered during its use. The factors were later organized to create a nurse experience journey map to identify different incidents that can occur during the timeline explained in the journey map.
Examples of patient safety incidents due to infusion pump errors include rapid injection due to use errors. There was a case where a patient arbitrarily removed the infusion pump and rapidly injected the medication that was connected to the pump, complaining of chest pain and breathing difficulties. In addition, there was a case where a patient who was injecting ketamine mixed intravenous fluids using infusion pump removed the pump without locking the clamp before MRI, and the medication was rapidly injected, causing consciousness change. These two examples were initiated by patients, but could have been prevented if precautionary measures were taken by the nurses.
The goal is to analyze the occurrence, cause, and solution of patient safety incidents that can occur within medical environments while using infusion pumps and organize the following process into a user experience journey map from a nurse’s point of view.
In order to understand the use of the infusion pump within the use environment, an interview was conducted with nurses working in two different wards in the hospital. Two nurses per ward were interviewed with 26 questions corresponding to three categories: medical environment, infusion pump use environment, and infusion pump use. After the interview, the collected records were systematically transcribed, coded, and grouped by category through thematic analysis. A nurse's experience journey map was created based on categories developed through coding, following the format of a patient journey map and tailored to the workflow of nurses using infusion pumps. The journey map is organized as follows: phase, sub-phase, event, touchpoint, themes and actions, emotions, experience and pain point, Picker's 8 principles, design challenge. “Event” category indicates medical device-related incidents that may occur in “phase” and “sub-phase” categories.
A new nurse persona, who is not familiar working with an infusion pump within the medical environment, was established to systematically classify possible incidents related to the infusion pump during a day shift. There are six representative tasks for nurses: patient identification, patient handover, rounding, regular medication administration, implementation of patient examination and surgery schedules. Infusion pump-related incidents that may occur during these tasks include intravenous fluids replacement errors, medical device alarms, near-miss incident with a medical device drop, and infusion rate errors. When these errors occur, the persona often experiences confusion and fear, which leads to stress and burden on their work. During the study, it was confirmed that improvements, such as enhancing the visibility of infusion pump settings, are necessary to prevent patient safety incidents related to infusion pumps and alleviate unexpected nurse workload. Various incidents that can occur within a nurse’s workflow were organized to analyze the cause of those incidents. In this study, factors related to the use of medical device were used to analyze what types of incidents can occur when met with certain factors and how those factors can be further considered during its use. The factors were later organized to create a nurse experience journey map to identify different incidents that can occur during the timeline explained in the journey map.
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