from Bing.com Dall-E3.
Prompt: please draw a nurse, surprised and concerned, receiving an alert from a computer, while dispensing a medication to patient.
See picture above, which at first glance looks reasonable. But then, increasingly disturbing. 1) How many arms does the nurse have? 2) Is the second person a patient or a nurse? 3) Is that a blister pack of pills or a blister pack of push-buttons? 4) What kind of triangle alert icon is that? 5) Nice hair.
Often, in our EHR committee work, we pursue “low hanging fruit.” For example, when we look at the analytics on “frequently overridden alerts” we see 95% override rate or more on some alerts. This means when we interrupt the physician, APP, or nurse, they disagree with the alert 19 times out of 20. Wow, that must be a nuisance alert.
In the past year, we have successfully eliminated hundreds of thousands of alerts per month by taking “frequent override” alerts, and after some research, forethought and clinical consensus, removing them.
Occasionally, though, we hit a snag.
Recently, a nurse reported that our removal of “Med Too Soon” which was overridden more than 95% of the time, caused an unanticipated medical error.
What’s that? We removed an alert that is ignored 95% of the time, and we have nurses who want to bring it back?!
What is going on?
Here is where meeting with your hardworking frontline users pays off.
I met with the nurse who reported the incident, and this is what she explained to me. As a result, I am a convert.
Situation: On the medical / surgical floor of a hospital, an increasing number of patients are recovering after their operation, and being prescribed an alternating dose of acetaminophen and ibuprofen, as needed, instead of the previous standard of a narcotic pain medication.
Because the 2 medications are “prn” taken as needed, and because the time between doses is highly variable, and none of our systems remind the nurse which “prn med” was last given, it is very easy, when selecting pills out of Pyxis med dispensing cabinet, to pick the wrong med: ibuprofen or acetaminophen, for the patient in pain.
When selected correctly, no problem, patient receives their pain med on time.
On the other hand, a busy nurse could easily select acetaminophen twice in a row, three hours apart, for a patient’s pain control during a busy shift for a patient’s pain control request, while juggling the clinical needs of 3, 4 or 5 other patients at the same time.
Here is where the alert is helpful.
As he/she arrives at the patient bedside, pills in hand, they will conduct the bar code scan to affirm the “5 rights” for med dispensing:
- Right patient
- Right medication
- Right dose
- Right time
- Right route
“Beep.”
if the right med is selected, no problem, and the time stamp of administration to patient is done. Otherwise
“BOOP”
alert, “MED TOO SOON.” Because “PRN meds” are not scheduled, neither the EHR nor the Pyxis machine pops up the suggestion for the right med. Even worse, when there is an alternating schedule for 2 different PRN meds, it is quite easy to pick the wrong one.
When the nurse hears “BOOP” a quick glance shows “less than 3 hours since last dose: Too Soon” it is easy to take the acetaminophen back to the cabinet and swap it out for ibuprofen. Whew! Good job everyone!
Yes, our valiant nurse is supposed to pay attention to such things. Yes, this is a particularly sticky situation. Yes, having a “safety net BOOP: MED TOO SOON” alert is highly valued in this situation (prn med with 2 alternating drugs).
Thus, even though 95% of the time “Med Too Soon” is a nuisance to those dispensing stable, scheduled (not-PRN) meds, for the other 5% of the time, this guardrail keeps an increasingly likely medical error from occurring.
Our EMO group turning off “Med Too Soon” removed this guard rail, and some (minor) medical errors resulted, with acetaminophen being given too frequently at times.
Now our job is to go back and subdivide this “Med Too Soon” alert into something useful for the ibuprofen/acetaminophen situation while removing the nuisance from other workflows. Back to work, EMO team!
The Lesson Learned:
Be humble. Medical care is not simple. Our clinicians are doing incredibly complex tasks every day. It is up to us to design systems to help them do the right thing. Sometimes theoretically smart decisions don’t survive the real-world test.
Try this yourself.
When was the last time, as an informaticist, you were out rounding or talking to front-line users about making their lives easier? And, why wasn’t it today?
