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Trusted Contributor
Posts: 141
Registered: ‎02-19-2010

Follow up to St. Mary's fatal error story

This was the front page article in today's Wisconsin State Journal:

 

Report: Systemic problems at St Mary's set stage for fatal drug error

 

This story became national news back in 2006 when it occurred, and has since been looked at closely in patient safety studies.  As awful as this event was, I was very glad to see St. Mary's took the time to really investigate the systemic problems.  The hospital has developed three solutions to prevent this error in the future, including increased use of medication bar code scanners. This is the sort of investigative work that needs to continue in order to promote patient safety. 

 

I would love to hear other's thoughts on the report and outcome of the investigation.

Trusted Contributor
Posts: 214
Registered: ‎02-18-2010
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Re: Follow up to St. Mary's fatal error story

Paul - Thank you for posting this! I saw this in the paper this morning too....

 

I found it interesting that when this occurred such a large percentage of staff were not using the bar-coding technology available to them consistently and that this was allowed by their supervisors. It looks like this has since changed, but I am curious if this is a common trend/hurdle that others have to overcome when implementing new technologies intended to increase patient safety.

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Occasional Advisor
Posts: 9
Registered: ‎02-19-2010
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Re: Follow up to St. Mary's fatal error story

Great post & I too would be interested to see if this a common hurdle.

VIP
Posts: 94
Registered: ‎02-26-2010

Re: Follow up to St. Mary's fatal error story

I can tell you from my own experience that it is definitely a common trend/hurdle to overcome when implementing new technology... especially when it comes to increased patient safety. Even when we were implementing Sentri7, there was some resistance from our pharmacists who look at it as just another thing that they have to do (that is, until they realized that Sentri7 cut down on the number of paper reports that they had to go through. I suspect that in another year or so, if we were to take away Sentri7, the pharmacists would probably revolt!).

 

I think that in order to be successful, new technology must have two properties: it must be incredibly easy to use, and it must genuinely cut down on the total amount of work required by the user.

 

One cannot simply add a new piece of software on nursing or pharmacy staff in the name of patient safety without taking something else away from them (either the technology replaces and improves upon an existing process, or existing processes are shifted to additional staff). Few employees are altruistic enough to want to take over additional processes simply for patient safety (and one cannot design workflow processes around these "super-employees" anyways), and so the first thing you have to sell is how the new technology is going to benefit them directly (having Sentri7 means no longer do they have to go through so many paper reports, and the fact that Sentri7 does some of the work for them is an additional benefit. Installing computers in the pharmacy means that labels no longer have to be typed out by hand, and the fact that computers can be designed to catch interactions the pharmacist could have missed is an additional benefit).

Graham O'Hea, Pharmacy Systems Analyst
Trusted Contributor
Posts: 141
Registered: ‎02-19-2010

Re: Follow up to St. Mary's fatal error story

Heather - Great question.  I'm going to reference my comments regarding violations I made in response Chris Beebe's blog: http://forums.pharmacyonesource.com/t5/Surveys-and-Safety-Strategies/Non-Punitive-Policies-and-Medic...   I know a couple of the patient safety experts at University of Wisconsin have used the St. Mary's story to show an example of a routine violation.

 

GrahamOH - I unfortunately have to agree with you that workarounds such as this seem to be pretty common.  I think it can stem from a few different causes; poorly designed and implemented technology, inadequate training, or even trying to use technology as a band aid to fix a process or system issue.

 

There is a great article that a group at UW published a couple years ago.  They observed nurse interactions with new BCMA technology and found 18 different use sequences.  Only two of the 18 followed written policy, and four of the sequences were deemed unsafe.  This is why I feel it is very important for technology companies and health care organizations to do their homework and really learn and understand clinical workflows.  Without this understanding, it makes it very difficult to design and implement technology to support safer patient outcomes.

 

And Graham...I have run into the same thing you mentioned with resisting new technology.  I think you made some good points on needing to show the benefits of the technology.  I feel it is important to establish trust in healthcare technology.  I've talked to physicians in the past that are concerned about the "black box" of technology and not feeling like they are in control.  To establish this trust, I feel you need to develop well designed, easy to use, reliable technology. 

Trusted Contributor
Posts: 141
Registered: ‎02-19-2010

Re: Follow up to St. Mary's fatal error story

Just as a follow up, I'm posting that article I referenced in my last post. 

Trusted Contributor
Posts: 214
Registered: ‎02-18-2010
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Re: Follow up to St. Mary's fatal error story

PaulM,

 

Thank you for posting that very informative article. Hopefully others find this useful information as well....

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Valued Contributor
Posts: 72
Registered: ‎02-22-2010

Re: Follow up to St. Mary's fatal error story