Full Answer Section

• Identify Root Causes:
  • System design flaws that allowed for easy override of safety features.
  • Inadequate training and education on HIT systems.
  • Organizational culture that did not prioritize patient safety.
• Generate Solutions:
  • Redesign HIT systems to improve usability and safety.
  • Implement mandatory training and competency assessments for HIT systems.
  • Develop clear policies and procedures for medication administration.
  • Foster a culture of safety and transparency.

D. Interprofessional Team Members:

• Pharmacist:
  • Expertise in medication safety and drug interactions.
  • Review medication dispensing processes and identify potential risks.
• HIT Specialist:
  • Expertise in EHR and medication dispensing system design and functionality.
  • Analyze system logs and identify usability issues.
• Nurse Manager:
  • Expertise in nursing workflow and patient safety.
  • Provide insights into human factors and organizational culture.
• Physician:
  • Expertise in medication ordering, and patient safety.
• Human Factors Engineer:
  • Expertise in the interactions between humans and systems.
• Risk Manager:
  • Expertise in risk assessment and mitigation.
• Legal Counsel:
  • Expertise in legal and regulatory requirements.

2. Design Strategies for Workplace Mitigation

A. Visual Representation:

• Flow Chart: A flowchart depicting the medication administration process, highlighting critical control points and potential error pathways. This flow chart would include each step of the process, and would highlight each interaction with the HIT systems. It would also show were redundant checks should be.

B. Changes to Policies, EHR, Equipment, and HIT Applications:

• Policies:
  • Implement mandatory double-checks for high-risk medications.
  • Develop clear protocols for overriding safety alerts.
  • Establish a “just culture” that encourages reporting of errors without fear of reprisal.
• EHR:
  • Redesign the user interface to improve usability and reduce cognitive load.
  • Implement redundant safety checks and alerts.
  • Integrate barcode scanning for medication verification.
  • Create hard stops, for high risk medications.
• Equipment:
  • Ensure that medication dispensing systems are properly calibrated and maintained.
  • Implement smart infusion pumps.
• HIT Applications:
  • Utilize clinical decision support tools to prevent medication errors.
  • Implement real-time monitoring of medication administration.

C. Communication/Transition Plan:

• Establish a communication team.
• Develop a communication plan that includes regular updates, training sessions, and feedback mechanisms.
• Utilize multiple communication channels (e.g., email, newsletters, meetings).
• Provide clear and concise information to all stakeholders.

D. Staff Education Plan:

• Change Theory:
  • Lewin’s Change Management Model (Unfreeze, Change, Refreeze) would be suitable. This model emphasizes the importance of preparing staff for change, implementing the change, and reinforcing the new practices.
• Educational Delivery Methods:
  • Interactive workshops and simulations.
  • Online learning modules.
  • Hands-on training with EHR and medication dispensing systems.
  • Role playing.
  • Case studies.

E. Metrics for Evaluation:

• Cognitive:
  • Post-training knowledge assessments.
  • Competency assessments on HIT systems.
  • Tracking of reported errors and near misses.
• Psychomotor:
  • Direct observation of medication administration practices.
  • Simulation-based assessments of medication administration skills.
  • Tracking of barcode scanning compliance.
• Affective:
  • Staff satisfaction surveys.
  • Qualitative feedback on the effectiveness of training.
  • Assessment of staff attitudes toward patient safety.