Savitz L, Bruce BK, Savitz L, Logsdon K; AcademyHealth. Meeting (2003 : Nashville, Tenn.).
Abstr AcademyHealth Meet. 2003; 20: abstract no. 852.
RTI, Health Care Quality, 3040 Cornwallis Road, Cox 260, Research Triangle Park, NC 27709 Tel. (919)316-3301 Fax (919) 541-7384
RESEARCH OBJECTIVE: An important part of ensuring patient safety is the effective transmission of medication information across care settings. Inaccurate or incomplete information is a leading cause of medical error. Members of the RTI IDS Research Network share an ongoing interest in identifying information technology solutions to enhance patient safety by minimizing the likelihood that such adverse medical events will ever take place.The overall purpose of this study was to gain an in-depth understanding of the medication information transfer process and identify likely process failures, which could be practically addressed. Our study included three phases: (1) Phase 1 was intended to gain an in-depth understanding of the problem; Phase 2 assessed the generalizability of our in-depth understanding and identified best practices for address such problems; and Phase 3 evaluated a specific solution at one IDS. The latter phase of this work focused on application of Failure Mode and Effect Analysis (FMEA), a common technique prescribed by JCAHO. STUDY DESIGN: This quasi-experimental study used various data collection approaches. A series of focus groups and in-depth discussions with clinicians at one IDS provided the basic foundation of information for constructing the care process model, identification of vulnerability points, and derivation of associated risk scores. Some chart abstraction and administrative data were used to quantify risk scores for select vulnerability points. This portion of our analyses involved a pre- and post-evaluation of a information technology solution to enhance the medication information transfer process using FMEA methodology. POPULATION STUDIED: Expert clinicians (i.e., nurses; pharmacists; social workers; primary care, hospitalist, and emergency department physicians) were engaged in the FMEA application, using data from the Providence Portland Service area (two hospitals, one tertiary care and one community) anchored by medical-surgical units in these facilities. PRINCIPAL FINDINGS: Key findings suggest that: (1) FMEA holds promise as an evaluation tool in determining unintended consequences and the degree of risk reduction associated with information technology solutions; (2) there are some methodological limitations associated with the scoring process; (3) it appears that basic FMEA inputs are transportable across IDS settings; and (4) and application of assessment tools such as FMEA are limited by the availability data and on-site analytic skill. CONCLUSIONS: We need to examine the methodological contribution that newer (to the healthcare industry) probabilitistic risk assessment methods such as FMEA can be used for evaluation purposes. Such methodological advances provide evaluative data that is useful to continuous quality improvement and the enhancement of implemented IT solutions. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: Policy makers and accrediting agencies (i.e., JCAHO) need to understand that practitioners and researchers do not necessarily have the training and skills necessary to apply newly adopted methodologies. Additionally, there is limited exposure to shared learning in how these transported methodologies need to be adapted for health care studies.
Publication Types:
Keywords:
- Biomedical Research
- Delivery of Health Care
- Epidemiologic Studies
- Evaluation Studies
- Health Services Research
- Humans
- Joint Commission on Accreditation of Healthcare Organizations
- Medical Errors
- Pharmacists
- Research
- Risk Assessment
- methods
- hsrmtgs
Other ID:
UI: 102275819
From Meeting Abstracts