Unintended Outcome: Technology Progression

Sharon Reynolds, RN, BSN, SCPM, Senior Solutions DHIMSS Clinical Informatics Insights

Two decades ago, paper MARs (Medication Administration Records) and manual pneumatic tube transmission of orders/results were fraught with errors. Today, pharmacy systems automatically intercept errors, safeguarding the patient. As they say, “we’ve come a long way, baby!”

As a pediatric and ICU nurse working in nursing administration, I began my consulting career in 1997, entering the HIT industry on the cusp of the soon-to-be released landmark report by the Institute of Medicine, “To Err is Human.” Naturally, the focus was patient safety.

In early 2002, a state health agency was threatening to close a northeastern university hospital for two infant deaths caused by overdosing.  I was co-leading an IT team implementing the facility’s first pediatric dose range checking system.  An unintended consequence of human behavior became apparent the first day of go-live. The hospital pharmacists disliked the generated printed labels so much that they created workaround, handwriting their own labels. Tragically, that day a pharmacist filled an order with a misplaced decimal point on a handwritten label and the wrong dosage was given to a third child.

We, the IT team, learned an unintended, but profound, lesson:  Validate that every physician, nurse and clinician uses the new system as designed to ensure workflow processes in place are being followed.

In those early years as a consultant, I observed another unexpected consequence of implementing integrated systems in a large hospital setting:  the “blossoming” of cross-departmental collaboration. After installing a new application together, hospital departments came away with a much better understanding and appreciation of their peers’ workflow processes. The resulting improved end user communications cleared up many misperceptions and ultimately positioned the patient as the focal point of interactions.

Other exciting and unexpected consequences of technology progression that I’ve witnessed over the course of my career include:

  • WOWs (Workstations on Wheels) have dramatically decreased patient falls by encouraging caregivers to document at the bedside thus having closer proximity to the patient. 
  • Implementing an enterprise system can standardize processes allowing the use of organizational best practices and sharing of personnel to areas experiencing high patient acuity.

Patients and their families can communicate with providers via technology. When I attended my aunt’s funeral, family members raved about how the patient portal kept them better informed resulting in a greater confidence in the quality of care provided to their mother. Incidentally, I was implementing an EHR at the very same hospital.

About the Contributor
At CTG Health solutions, Sharon Reynolds serves in a delivery oversight capacity for the Cerner and implementation. She is a registered nurse with more than 27 years in the healthcare industry, over 16 years specifically in healthcare IT. Reynolds has significant knowledge in clinical project management, systems implementations and system selections for clinical applications. Reynolds is a Stanford Certified Project Manager in Advanced Program Management. Her operational experience as a clinician is in acute care hospitals with an emphasis in nursing administration, critical care and pediatrics.