Before I start getting too deep into this blog, I think it would be fair to share the framework behind my patient safety philosophy.
I mentioned in my first entry what I believe is the key point behind patient safety: Care givers are human, and humans make mistakes. This means an assumption needs to be made that mistakes can and will happen. In order to protect patients, a 'system' must be put in place to reduce the amount of errors and to prevent an error from causing harm. What is this 'system'?
The 'system' covers everything and everyone the care giver interacts with. I like to explain this with the University of Wisconsin System's Engineering Initiative for Patient Safety (SEIPS) model.
According to the model, the healthcare work system is broken into the following components:
- Person - The care giver is at the center of the model. The person component also covers interactions with other people, including the patient.
- Tools/Technology - The tools and technology the care giver requires. This can range from paper and pencil to computers.
- Tasks - The tasks required by the care giver to treat the patient. Documenting a lab result, transcribing a prescription, and talking with a patient are all examples of healthcare tasks.
- Environment - This piece covers the physical environment the care giver works in. Adequate lighting, the location of computer terminals, protection from hazards all fall under environment considerations.
- Organization - This looks at the rules and regulations handed down from management in the hospital. The culture of that the care giver works in also falls under organization.
When combined with the processes put in place for the care giver, the work system will affect patient outcomes. The theory is that every piece of the system is important in order for someone to do their job successfully. If any component is inadequate or fails, the work system of the care giver will become unbalanced and increase the likelihood of harm. I like to think of this as a puzzle where all the pieces need to fit together properly around the patient. The SEIPS model is the framework I fall back on when considering how technology I help design fits into the healthcare system.
A quote I read recently in "Why Hospitals Should Fly" drives home the importance of taking a system approach to patient safety: "Every system is perfectly designed to get the results it consistently achieves." What would it take for the system to achieve zero patient injuries?