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Tag: End to End Monitoring

B+ when transfusing blood.

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Blood Groups

Blood transfusions in hospitals are a common occurrence to treat a number of conditions and diseases, from traumatic events to sickle cell. They are becoming more and more common for a variety of conditions, it now a medical specialty called transfusion medicine. Blood must be matched, at a minimum by type (ABO compatibility) for emergencies, but as transfusions have become more common to treat other conditions, additional testing and matching will occur for various other antibodies. Transfusions are largely regarded as a last resort when other treatment methods have failed, and related critical events are rare, depending on source 0.2%-1%, but they are still common and necessary occurrences. Critical to the safety of transfusions is ensuring that right blood gets to the right patient.

Each blood component must be tracked to ensure that when a patient needs it, they are receiving blood that is compatible, from the blood type to different antibodies in the components. Information systems help ensure this safety by providing a means for tracking blood products, which go through multiple processing steps after donation and are often collected far from the recipient.

Once blood products arrive in the hospital, they will often undergo additional testing to further discriminate sub types and antibodies. Patients that have received multiple transfusions are more likely to have antibodies against certain bloods, increasing the risk of a transfusion, increasing the need for more checks. Within the hospitals ordering blood products follows a similar pathway to medication ordering and administration, which was discussed in last week’s blog.

Similar to pharmacies, blood banks (where the blood is stored and distributed) often have a dedicated system for testing and tracking blood products. These systems are connected to the hospitals EHRs for physician ordering, distribution, and finally administration by the nursing staff. At any point along the chain if a connection is broken there can be a safety consideration that is missed. Healthcare workers are extremely vigilant when ordering, dispensing, and administering blood products, each step along the way involves checks and double checks to ensure safety.  As complexity in matching grows, the risk for missing a critical element increases.  As a safety double check blood products will be electronically scanned at each step, including administration, to make sure the right blood is being administered.

As the utilization of blood products increases to treat more and more diseases and conditions, and more specific matching becomes ever more critical, there is always an increased likelihood that a break in one of these systems can cause a critical check or piece of information to be missed. Transfusion events are rare, but they do occur, and it is often because of an unknown on the patient side. Until a patient receives a transfusion, we may not know how they will react.

If a transfusion event does occur, there is a process that occurs to figure out why. Critical to this process is knowing what blood was administered, it’s components and sources, and why the patient had a reaction. All of this information is documented, not only in the EHR, but also in the blood bank systems, to ensure that the risk of future events can be minimized, not only for that patient, but for other patients as well.

Interconnected systems ensure the safety of the blood supply and the safe administration of life saving therapies for patients in need. Are we positive these systems are operating as they should be? Can we B+ that all critical information and safety checks are happening as expected?

Tido provides automated end to end monitoring solutions that will automatically alert your teams there is a disruption.

Blood donation and transfusions remain safe and effective treatments to help those in need. For more information on donating blood, please visit the American Red Cross.

Systems reliability and the impact on safe medication administration.

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Medications Tablets

 

Inter-operability among systems in healthcare offers great hope for the exchange of patient information, ensuring clinicians are acting on the most up to date information possible and offering a double check for safety. Technology has become so central to a functional clinical environment that it powers pharmacy systems, saving time by performing critical checks. This technology has become so entrenched in the hospital that there are alerts and checks at almost every point of the medication transaction, from the time of order right through to administration.

How much can technology help patient safety? According to the NIH computerized physician order entry has reduced serious medication errors by 55%. Patient wrist band scanning is associated with a 51% decrease in adverse drug events at the time of administration. All of these systems, from prescribing to administration require connections to function properly.

The systems are there as a double check for patient safety, in a busy patient care environment mistakes can happen due to quick glances at labels or errors in manual dose calculations. No clinician wants to harm their patient, and we’ve come rely on these systems to make sure we haven’t missed anything. What happens when these systems are bypassed? Most of the time nothing happens, most errors may result in administration at the wrong time, or a dose that is not therapeutic. However there are times when a medication error can cause harm, at the most extreme death from an adverse drug event.

Why would any clinician bypass these safety systems? Emergencies are one area where automated safety checks are bypassed and manual checks are the norm. The other is when connections are down. If allergies aren’t updated in a pharmacy system from the EHR, an interaction may be missed. If medications aren’t updated from the pharmacy to the EHR, doses may be missed or medications over-ridden in the dispensing system.

Who monitors these connections to ensure they are operating? Most often, nobody. They are assumed to be working until someone reports a problem, because most of the time they do work.

Picture a busy unit in a hospital and let’s consider a broken connection between pharmacy and the medication cabinet.

    • Physician enters the order in the EHR, it is sent to and received by the pharmacy system.
    • Pharmacy reviews and approves the medication to be removed from the cabinet.
    • Nurse sees the order, 30 minutes later goes to the cabinet, does not see the medication on the patient’s list, and overrides it to give to the patient because they need it (safety concern).
    • The nurse double checks the patient, medication, dose, route, allergies to confirm the medication is appropriate, does not check interactions because they are in a rush and the patient is only on a few meds. (safety concern).
    • Nurse administers the medication, but has to override the bar code scan because the approval was not received from pharmacy (safety concern).
    • The nurse assumes pharmacy is just slow and goes on with their day.

In this instance, there is no error and no harm, everything went as expected despite the nurse missing the check for interactions. Will that be the same for the next nurse administering the next medication? It may not be several hours until the nurses realize that no new medications are being approved from pharmacy, at which point someone will call pharmacy, who will call the IT help desk. This will begin a chain of tickets to IT specialists and vendors to start checking pharmacy feeds. Several hours and countless medication administrations after the feed went down.

This isn’t a made up scenario, it occurs countless times in hospitals all over the country. Hospitals rely on physicians, pharmacists, nurses and others to manually check when systems go down. But if nobody realizes the system is down, some checks might get missed. This poses a safety concern for patients and removes critical check for busy staff who rely upon it. It could take an entire shift for a nurse, doctor, and pharmacist to manually check every medication for a single critical patient.

What if these systems could be automatically monitored and IT teams notified immediately if a feed was interrupted? Staff that rely on safety check in systems can rest assured that they are working, that the system is operating as intended. If there is a problem, they can be quickly notified and make sure they are following processes meant to ensure safety when systems cannot.

Tido provides automated end to end monitoring solutions, that will automatically alert your teams when there is a disruption.

Low visibility tech that has a high impact for clinical staff.

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Cath Lab Technology

How to avoid staff sentiment of “nothing works like it’s supposed to.”

Low visibility tech that fits so seamlessly into a workflow, we don’t know it’s there until it tells us it is.    Tech that actually saves clinical workers time and allows them to focus on patients, could it exist?

Absolutely.  There are so many systems healthcare is reliant upon, when they fail to connect, big problems arise that will have a big impact on clinical workers.  This can be such a problem that many clinical areas within hospitals will dedicate a person to check information is flowing where its supposed to.  They are not IT, they are patient care professionals taking time to check these systems because they know the problems that arise when patient information doesn’t flow.

Consider a Cardiac Catheterization Lab, the simplest lab might have 3 different systems, the most complex, maybe 10 or more.  A typical solution to checking systems within a lab:

  • Everyday, or every week, a Cath Technician or Nurse may spend 3 – 5 hours checking reports to make sure they went to the EHR, and images to make sure they went from the local system to the PACS/VNA/EHR/DICOM.  At best any interruption in transfer is caught before the patient leaves the procedure area, at worst, it is not caught until someone is looking for the results.
  • Once the interruption is caught a staff member will check operations on their end to make sure it wasn’t an issue with what they did.  Then they reach out to the IT help desk to report the problem.  IT will ask several questions and have the staff member perform checks manually to make sure everything was done correctly on the user end again.  
  • At this point the IT help desk will forward the ticket to another area or vendor if needed.  In a serial manner, the issue will get passed until the proper team or vendor is found that controls the part of the feed that was interrupted.

This is what happens during normal operating hours.  Most interruptions to connections occur when upgrades to one of the systems happen, most often during the night or weekends when staffing is lightest.  Cath labs have staff that are on call for emergencies, but not on site during those times.  If they are called in for an emergency they may discover the problem when they arrive and have a ‘network failure’ message on one of the systems, or it may not be discovered until after they have left the building and someone is looking for more information.  This will result in the physician or staff being called at home to provide the missing information.

Systems that don’t connect will inhibit the flow of patient information, and frustrate staff trying to provide patient care, this often leads to the sentiment “nothing works like it’s supposed to.” 

Low visibility tech that monitors these feeds can save staff time when things are operating normally, and can save frustration when its not by alerting the right people; often before the issue is even noticed by the user.

Imagine a Cath Lab solution with such a technology in place:

  • Cath Lab Technologist or Nurse is providing patient care, not checking different systems.
  • Feed from the imaging system is interrupted and a message alerts the appropriate IT team and/or Vendor as well as the Cath Lab.  In an ideal world this will be done on a hospital’s secure messaging platform so everyone can communicate a problem or resolution instantly.
  • All teams are checking for a problem on their end simultaneously.
  • Cath lab calls IT, confirms they have checked systems on their end, they are told that problem is known about and all teams are looking into it at the same time.
  • From experience we know that by the time the Cath Lab team finishes checking systems on their end, the other teams will have too.  The problem is often resolved by the time the Cath Lab is calling the help desk.

Since most interruptions occur during an upgrade, if the problem is found immediately, the IT team is notified immediately, likely before they are even finished with the upgrade and have left for the night.  

Implementing such a solution means you have freed up 3-5 hours per week of a highly trained patient care worker, and eliminated a major source of frustration for caregivers when systems don’t connect.  Low visibility tech that ensures smooth and hassle free operations for your staff, allowing them to focus on what really matters, the patient. 

Talk to Tido about their end to end monitoring packages to let your staff focus on their patient.

 

Changing role of risk management with expanding healthcare technologies and digital transformation

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Healthcare organizations identify and evaluate risks as a means to reduce injury to patients, staff members, and visitors within an organization. Traditionally risk management has focused on patient safety and the reduction of medical errors. But with the expanding role of healthcare technologies and expedited digital transformation because of the COVID-19 pandemic, healthcare risk management has become more complex over time.

In May of 2017, Moody’s Investor Services released a report highlighting the link between risk management and a hospital’s operating margins: “Maintaining high clinical quality will increasingly impact financial performance and reduce the risk of brand impairment as reimbursement moves away from a fee-for-service model and towards a greater emphasis on value and outcomes.”

For above reasons, hospitals and other healthcare systems are expanding their risk management programs from ones that are primarily reactive and promote patient safety and prevent legal exposure, to ones that are increasingly proactive.

A medium or large hospital typically has anywhere from 500 to 800 health information interfaces between health systems for registration, orders, results, charges, etc. With the expanding technologies, there are increasing number of electronic systems used in various departments and specialties. These systems are either hosted internally or increasingly hosted in the cloud.

With increasing number of systems and in turn increasing number of interfaces between systems, it is becoming a risk to rely on manual reporting of system issues in production environment. It typically anywhere from 40-60 min to identify an issue in live environments and its’ completely reliant on users finding the issue and informing help desk to begin the process of diagnosing and fixing the issue on hand. Prolonged system issues in live environment can lead to potential adverse patient outcomes because of missing critical information.

Enterprise risk management strategy of an organization are considering using proactive automated live system checks and interfaces monitoring to reduce risk associated with increasing number of electronic systems and applications in healthcare.

Learn more about Tido’s End to End Systems Monitoring to automate live systems issues detection and significantly reduce time to diagnose and resolve potential patient safety issues.