Presentation
Does More Accuracy Always Mean Safer Care? A Human Factors Perspective
DescriptionJust because the technology exists, does it mean we should use it? Imagine that there is a technology out there that can identify drug names and concentrations before they are given and measure the volume of medication delivered to a patient through IV tubing, then automatically record it in the patient’s chart (EMR). Imagine that this technology has the ability to measure drug volumes with an accuracy of +-0.1mL. Imagine placing this technology in an operating room where the average user (an anesthesia care provider) currently has no technology available to assist with medication identification or drug measurements, so their medication chart is often completed retroactively, and based on hand-written notes, best guesses and cues from the vials and syringes left in their space.
Do we expect the user to adapt to using this new, disruptive technology, or do we expect the new technology to adapt to the user’s current practices? Let’s explore the pros and cons of each scenario. But, before we do that let me provide a little more background on the device design. Let’s imagine this is a small, portable device that has a touchscreen graphical user interface (GUI). The GUI displays the measured medication dose recording to the user, but the user has the final say in what dose is recorded in the patient EMR; users have an opportunity to manually edit all dose recordings on the device itself before those doses make it to the EMR. Real-time dose editing is not required but is an option. The user can either manually edit the dose in the moment, do it later in the case, or not do it at all (i.e., accept the dose recording measured by the system).
Now, back to our previous question - Do we expect the user to adapt to using this new technology, or do we expect the new technology to adapt to the user’s current practices? Let’s explore the pros and cons of each scenario.
Scenario 1: Force the user to adapt to the new technology, meaning, provide them with the granularity that the system is capable of, and make them edit the dose recording to a more palatable, neater, or rounder number if they so desire.
• Pros:
o the medication chart is more accurate, therefore there is a perceived increase in patient safety.
• Cons:
o requires a paradigm shift for the anesthesia industry; providers may spend more time eyeing the chart and being confused because it contains unconventional medication doses.
o increases the amount of time a user is interacting with the system vs. providing patient care.
o increased interaction rate with the system could increase the instance of data entry errors.
Scenario 2: Make the new technology adapt to the user, meaning, program the system to be smart enough to round specific medications to the closest desired palatable, neater, or rounder number based on slews of data on anesthesia provider industry norms.
• Pros:
o the charted medications match industry standards and current practices for charting.
o the user doesn’t have to spend as much time editing doses and can focus more on patient care.
o there is less chance for medication charting errors if the user isn’t constantly adjusting doses.
• Cons:
o the medication chart isn’t as accurate as it could be given the technology, a potential missed opportunity for patient safety.
Assuming the smart-rounded dose recordings convey equivalent therapeutic effects, side effects and info for downstream treatment decisions as the more accurate (granular) dose recordings, which scenario is best? Does being more accurate always mean being safer? Or can avoiding unnecessary precision actually enhance patient safety? Let’s explore an example:
Ephedrine, an anesthesia medication used to treat hypotension, is often prepared at a concentration of 5mg/mL and administered in the following standard dose amounts: 5mg (or 1mL), 10mg (or 2mL), 15mg (or 3mL) or 20mg (or 4 mL). Let’s say an anesthesia provider draws up what they eyeball in the syringe as 2mL and the deliver the entire dose.
In Scenario 1, the medication recording system registers that 1.8mL was administered and displays a total measurement of 9mg. However, the anesthesiologist doesn’t want this unconventional dose to appear in the chart and they know the volume was very close to 2mL, so they edit the dose to 10mL, which was the intended dose.
In Scenario 2, the medication recording system registers that 1.8mL was administered but rounds this up to 2mL (the known standard dose closest to 1.8mL) and displays a total measurement of 10mg. The anesthesiologist is satisfied with the dose that will appear in the chart so doesn’t edit anything, since this was the intended dose and what they thought they administered.
In both of these scenarios, the number that ends up in the patient chart is the same. But which scenario contains more risk (for the user and the patient)?
Now you may also imagine a scenario in which the user edits the dose but inadvertently makes a data entry error when doing so, resulting in a totally inaccurate dose recording. Or, you may imagine a scenario in which the user accepts the smart rounded dose recording even though it is not 100% accurate, and for a controlled substance like fentanyl, how that might present a problem when it is time to reconcile the drug at the end of the case.
As you can see, there are upsides and downsides to both approaches. Based on our interactions with regulatory bodies, it has become evident that there’s a perception that more accuracy = more safety. However, we wonder if that is always the case. Maybe conforming to current medication charting standards is safer in some ways than trying to incite a total paradigm shift in an industry full of anesthesia providers who are accustomed to charting a specific way. Springing innovations on users that fundamentally change the way they currently think, behave, and operate may be riskier than offering a middle ground system which still has a strong value proposition and meets users closer to where they currently are.
At this point in time, we don’t have specific HF data to compare the safety of the two versions of the system. However, we have future plans to conduct research with the hypothesis that the smart rounding feature (with decreased accuracy) is at least not less safe than the feature with increased accuracy.
Let’s assume the results of our future research indicate that the smart rounding feature is less safe than the granular measurement feature. If the granular technology isn’t likely to be widely adopted by the industry, the other inherent safety features of the technology will not be realized. So, what’s safer in that scenario – non-utilization of the technology as a whole, or utilization of the technology with the ‘riskier’ smart feature?
Do we expect the user to adapt to using this new, disruptive technology, or do we expect the new technology to adapt to the user’s current practices? Let’s explore the pros and cons of each scenario. But, before we do that let me provide a little more background on the device design. Let’s imagine this is a small, portable device that has a touchscreen graphical user interface (GUI). The GUI displays the measured medication dose recording to the user, but the user has the final say in what dose is recorded in the patient EMR; users have an opportunity to manually edit all dose recordings on the device itself before those doses make it to the EMR. Real-time dose editing is not required but is an option. The user can either manually edit the dose in the moment, do it later in the case, or not do it at all (i.e., accept the dose recording measured by the system).
Now, back to our previous question - Do we expect the user to adapt to using this new technology, or do we expect the new technology to adapt to the user’s current practices? Let’s explore the pros and cons of each scenario.
Scenario 1: Force the user to adapt to the new technology, meaning, provide them with the granularity that the system is capable of, and make them edit the dose recording to a more palatable, neater, or rounder number if they so desire.
• Pros:
o the medication chart is more accurate, therefore there is a perceived increase in patient safety.
• Cons:
o requires a paradigm shift for the anesthesia industry; providers may spend more time eyeing the chart and being confused because it contains unconventional medication doses.
o increases the amount of time a user is interacting with the system vs. providing patient care.
o increased interaction rate with the system could increase the instance of data entry errors.
Scenario 2: Make the new technology adapt to the user, meaning, program the system to be smart enough to round specific medications to the closest desired palatable, neater, or rounder number based on slews of data on anesthesia provider industry norms.
• Pros:
o the charted medications match industry standards and current practices for charting.
o the user doesn’t have to spend as much time editing doses and can focus more on patient care.
o there is less chance for medication charting errors if the user isn’t constantly adjusting doses.
• Cons:
o the medication chart isn’t as accurate as it could be given the technology, a potential missed opportunity for patient safety.
Assuming the smart-rounded dose recordings convey equivalent therapeutic effects, side effects and info for downstream treatment decisions as the more accurate (granular) dose recordings, which scenario is best? Does being more accurate always mean being safer? Or can avoiding unnecessary precision actually enhance patient safety? Let’s explore an example:
Ephedrine, an anesthesia medication used to treat hypotension, is often prepared at a concentration of 5mg/mL and administered in the following standard dose amounts: 5mg (or 1mL), 10mg (or 2mL), 15mg (or 3mL) or 20mg (or 4 mL). Let’s say an anesthesia provider draws up what they eyeball in the syringe as 2mL and the deliver the entire dose.
In Scenario 1, the medication recording system registers that 1.8mL was administered and displays a total measurement of 9mg. However, the anesthesiologist doesn’t want this unconventional dose to appear in the chart and they know the volume was very close to 2mL, so they edit the dose to 10mL, which was the intended dose.
In Scenario 2, the medication recording system registers that 1.8mL was administered but rounds this up to 2mL (the known standard dose closest to 1.8mL) and displays a total measurement of 10mg. The anesthesiologist is satisfied with the dose that will appear in the chart so doesn’t edit anything, since this was the intended dose and what they thought they administered.
In both of these scenarios, the number that ends up in the patient chart is the same. But which scenario contains more risk (for the user and the patient)?
Now you may also imagine a scenario in which the user edits the dose but inadvertently makes a data entry error when doing so, resulting in a totally inaccurate dose recording. Or, you may imagine a scenario in which the user accepts the smart rounded dose recording even though it is not 100% accurate, and for a controlled substance like fentanyl, how that might present a problem when it is time to reconcile the drug at the end of the case.
As you can see, there are upsides and downsides to both approaches. Based on our interactions with regulatory bodies, it has become evident that there’s a perception that more accuracy = more safety. However, we wonder if that is always the case. Maybe conforming to current medication charting standards is safer in some ways than trying to incite a total paradigm shift in an industry full of anesthesia providers who are accustomed to charting a specific way. Springing innovations on users that fundamentally change the way they currently think, behave, and operate may be riskier than offering a middle ground system which still has a strong value proposition and meets users closer to where they currently are.
At this point in time, we don’t have specific HF data to compare the safety of the two versions of the system. However, we have future plans to conduct research with the hypothesis that the smart rounding feature (with decreased accuracy) is at least not less safe than the feature with increased accuracy.
Let’s assume the results of our future research indicate that the smart rounding feature is less safe than the granular measurement feature. If the granular technology isn’t likely to be widely adopted by the industry, the other inherent safety features of the technology will not be realized. So, what’s safer in that scenario – non-utilization of the technology as a whole, or utilization of the technology with the ‘riskier’ smart feature?
Authors
Event Type
Oral Presentations
TimeTuesday, March 2411:15am - 11:37am EDT
LocationMurray Hill East
Patient Safety Research and Initiatives