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Patient Safety and Usability: Experiences in the U.S. Department of Veterans Affairs

Many of us, through our own experience or the experiences of loved ones, realize the paradox of promise and perils in modern healthcare’s complexities. For nearly a decade, healthcare organizations around the world have worked to improve the safety of the care they provide. The patient safety movement rests on principles of human performance and systems thinking that are also basic components of usability engineering. This perspective on patient safety acknowledges the importance of designing usability into tools, processes, and environments to foster systems resistant to inevitable human error.

The United States Department of Veteran Affairs’ (VA) Veterans Health Administration served 5.5 million patients in 2006. It has, from the beginning, been a leader in the systems-based approach. Patient safety efforts in VA aim to build fault-tolerant systems that reduce the likelihood of patient harm. Three supporting initiatives within VA are the National Center for Patient Safety (NCPS), the Office of Information Patient Safety Program, and the Bar Code Resource Office.

The Patient Safety Movement

In 1999, the Institute of Medicine of the U.S. National Academies report “To Err is Human” estimated that between 44,000 and 98,000 inpatient deaths occur annually in the U.S. due to patient safety events, with a related cost of $17-29 billion. In that same year, the Veterans Health Administration of the Department of Veterans Affairs formed the National Center for Patient Safety (NCPS). NCPS continues to promote a culture of safety throughout t he 155 hospitals in the VA system.

The 2003 National Patient Safety Goals set forth by the Joint Commission—which evaluates and accredits nearly 15,000 health care organizations and programs in the United States—constitute another important landmark in the patient safety movement. The original patient safety goals addressed patient care in inpatient hospital settings. In the intervening years, the goals were expanded to cover a wider range of healthcare settings.

Example of a National Patient Safety Goal and How VA Met It

In 2003 the Joint Commission created a goal to achieve correct site, correct patient, and correct procedure surgery. This goal addressed reported incidents involving surgical procedures performed on the wrong patient or involving an incorrect procedure on the correct patient. This goal is now a Joint Commission “Universal Protocol,” a permanent standard in surveying hospitals for accreditation.

In January 2003, the NCPS implemented the directive “Ensuring Correct Surgery,” which laid out a standardized comprehensive blueprint for the 163 hospitals then in the VA hospital network. NCPS created the directive based on root cause analyses registered in its patient safety database, grounding the processes put forward on experientially-based organizational learning. The directive includes five steps:

  1. The consent form is administered and executed properly
  2. The operative site is marked
  3. The patient is actively identified using required techniques
  4. A “time-out” briefing is conducted in the operating room (or) prior to starting the procedure
  5. At least two members of the team review pertinent radiological images prior to commencing the surgical procedure.

The first three steps support accurate identification of the patient, the procedure, and the correct surgical site. The fourth step requires that surgical team members actively verify a shared knowledge of these three key elements of the procedure they are about to perform. The final step provides verification that the correct medical images are present and are displayed in the correct orientation during the procedure.

two adaptors, one green, one clear
Figure 1. Avoiding color-coding miscues

Example of a “Strong” Fix

The strongest approach to reducing patient safety vulnerabilities is to “design out” the characteristics of objects or environment that increase the potential for patient harm.

In U.S. hospitals, wall outlets for medical gases are color coded green for oxygen and yellow for room air. The wall outlets require a Christmas tree-shaped plastic adapter in order to connect tubing to deliver gas to the patient. Common practice involves using color-coded yellow and green adapters, which sometimes were mismatched–yellow adapter attached to the oxygen wall outlet, green adapter attached to the room air outlet (see the illustration below). These mismatches increased the likelihood that a care provider would connect tubing to the wrong gas, since the providers look to the color of the adapter as they connect the tubing to it.

To reduce the likelihood of such mix-ups, the VA’s National Center for Patient Safety introduced clear plastic adapters to replace the yellow and green adapters that led to mix-ups. This cost-effective solution works with the existing hospital infrastructure for the piping used to deliver these gases, and forces the care provider to look directly at the wall outlet to identify and select the medical gas outlet, reducing the risk of mix-ups.

Patient Safety and VA’s Electronic Health Record

The Office of Information Patient Safety Program, started in September 2002, addresses the patient safety features of VA’s Computerized Patient Record System (CPRS) in use at all VA healthcare facilities. The facilities now analyze all issues classified with potential patient safety implications and prioritize them for improvement. Solutions seek to design out the harm when possible.

One example involved the electronic medication prescribing system in CPRS. An earlier version of the system used the first three typed characters of the medication name to find a match in the medication database, and then automatically completed and selected the drug name. With the redesigned system, the care provider now must deliberately select the item from a list of medication names that appear after typing in the first three letters. This fix applies the human factors principle of forcing a conscious action by the user to emphasize accuracy, as opposed to using a time-saving, auto-selection mechanism.

VA’s Premier Medication Safety Technology: Bar Code Medication Administration (BCMA)

In 1994 the Colmery-O’Neil VA Medical Center in Topeka, Kansas, piloted the use of bar codes to match patients positively with their medications. All dispensed drugs carry bar codes, and nurses scan these at the bedside, along with the bar code on the patient’s wristband, to ensure the correct patient receives the correct medication.

photographs of nurse administering to patient
Left: Barcode scanning of medication. Right: Barcode scanning of patient wristband to cross-check.

In 2000, senior VA leadership demonstrated commitment to this patient safety technology by implementing BCMA throughout all inpatient VA hospitals. Studies demonstrate that the BCMA system reduces medication errors to one third of pre-implementation levels.

The technology relies on computerized medication carts and VA-developed software. Starting in 2001, the bar code program began using cognitive engineering and human factors to improve the usability of these components. Today these activities include the application of user evaluation methods to optimize the design of the software user interface and to guide facilities in employing user-centered research for computerized medication cart selection.

Methods of user evaluation for software range from remote testing supported by NetMeeting and teleconferences, to elaborate face-to-face testing of innovative prototypes for highly critical tasks. Data from these evaluations result in improved navigation, layout, and content for software releases. For computerized medication cart selection, hospital facilities include more robust evaluation of equipment in the actual environment of care.