Some unanticipated consequences of the implementation of a hospital IT system:

1. Some unanticipated consequences of the implementation of a hospital IT system: learning from a case study Sabi Redwood Joel Minion Mary Dixon-Woods Anna Rajakumar UgochiNwulu

2. Introduction • Implementation of hospital IT systems to reduce errors and improve practitioner performance • As with any new intervention, we need to be vigilant to unanticipated consequences (both positive and negative) • Short case presentations to stimulate discussion about how organisations can detect and anticipate these consequences.

3. IT Systems as a Training Tool • Department of Health / NIHR funded • Includes up to 10 ethnographic case studies • Focus on innovative schemes to improve Q&S • Observations/interviews at sharp & blunt ends Quality & Safety in the NHS • Case study of large urban teaching hospital • Focus on CPS developed in-house over 10 years • Empirical data collected through observations on wards, at CPS-related management meetings, and in hospital pharmacy Computerised Prescribing System (CPS)

7. IT System as a Pharmacy Training Tool • CPS tablets used routinely by pharmacists on wards to: • review patient medications and test results • assess discharge summaries • prep patients for surgery (e.g. starting/stopping certain medications) • CPS also used to encourage pre-registration pharmacists to think critically • During rounds, typical training-type questions included: • “Look at this drug chart and tell me why the patient was admitted.” • “Look for possible interactions in this list.” • “Tell me what you see.” → “Explain why two opiates were prescribed.” • Junior pharmacists were also encouraged to assess the pharmaceutical implications of test results available through CPS

8. Enhanced Training Functionality of CPS • Ready access to patient information • drug chart • dose administration chart • test results • link to BNF • Portability to move easily within ward • e.g. reviewing meds while checking bedside lockers • Need to think critically about limitations of in-built clinical decision support • Opportunity to review care plans more broadly, looking for potential or real medical errors of other health care professionals

9. Generating the risk of new errors in the medication prescribing and administration process • 15% of all medication related errors were considered sociotechnical incidents. These incidents were further divided into types of sociotechnical error. • Missing electronic signatures on administration (49%) • Technical slips or lapses during prescribing/administration (31%) • Training related (5.5%) • Mixed economy related (11%) • Prescribing privileges (2.7%)

10. Issues raised by studying medication errors in a highly computerised hospital: • Creates auditable moments through heightened visibility • Potential instrument to monitor staff • Mixed economy of prescribing systems during roll out.

11. Why is it important to understand the sociotechnical nature of medication errors? • Clinical and technical implementers can design out these unintended problems • Training needs and weak spots can be highlighted • Clinical practice protocols can be revised and designed to suit effective working practice.

12. HN000 HN000 HN000 HN000 HN000 HN000 HN000 Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Unintended consequences of computerised prescribing systems: diminished professional expertise? WITH

13. Using technology to increase patient safety at the hospital level … Total safety = Safety imposed + Safety managed * • Individual clinical prescribing skills: • Improved by education • and examinations • Expertise gained through • experience • Adaptive through • clinical discretion • Clinical Decision Support for e-prescribing: • Uses technology to • “impose” guidelines • Reduces the impact of • differing clinical • competencies Reduction in prescription errors ...does this affect professional expertise at the clinician's level? *Amalberti, R. Optimum system safety and optimum system resilience: agonist or antagonists concepts? (2006)

14. HN000 HN000 HN000 HN000 HN000 HN000 HN000 Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Mouse, Mickey Junior Doctors’ Dashboard project • Focus groups of junior doctors will explore: • Their response to working with a safety-focussed IT system • How they feel using the system affects their competence to prescribe • Their views of working outside the trust, without computerised prescribing systems designed for patient safety.

15. “The quality of paper is not strain’d” or the persistence of paper in health care work

17. Print outs as display medium for quick reference for planning and collaborative tasks • Transcription of electronically available patient data into paper notes • To enable alignment with incompatible systems (i.e. pharmacy) • Temporary, handwritten data storage for later entry into the computer (electronic observations)

18. Questions What methods can the ‘sharp end’ and the ‘blunt end’ of health care organisations use to help detect unanticipated consequences? How can organisations learn about unanticipated consequences in their sociotechnical context? What methods can social researchers use to generate knowledge to help organisations anticipate consequences?