Learning Center

Introduction/Setting the Stage (15min)

Effects of the Pandemic on Health Care Delivery and Impact on Patient Safety

The modern patient safety movement predated the massive digitization and technological transformation of health care that has occurred over the past 20 years—and therefore the modern patient safety movement by necessity began with a focus on social systems, human behavior, team behavior, and accountability. It is widely recognized that this approach has not achieved significant and enduring improvements in patient safety. Health care systems are experiencing additional headwinds that make social approaches to improving safety even more difficult: pandemic-induced staffing shortages, turnover, loss of those with expertise, new-to-practice staff less prepared for the clinical world, staff burnout and fatigue, and supply chain disruptions. In 2022, health care has become sociotechnical work, where the machines are no longer our tools; they are out partners. This massive digitization enables a systems-based approach to designing operating systems that both facilitate outstanding care and prevent harm.

The Role of Human Factors and Resiliency Engineering in Advancing Patient Safety in Health Care

In complex sociotechnical environments, operating systems largely determine the outcome. Clinical operating systems and safety management systems inform and define the safety behaviors of an organization, and therefore the culture of safety. It is important to design tools, technology, and processes that do not exceed the capability and capacity of those using the system. We need to hold our operating systems and safety management systems to the same high professional standards to which we hold ourselves. By incorporating human factors and resiliency engineering principles, organizations can identify areas of risk in the clinical operational systems that can impact patient safety. In this session, we will explore key strategies, operations, and tactics that will aid in reducing errors, that will avoid turning errors into failure, and that will keep any failure from spreading; we will also explore the role of nurses as an integral part of the team’s ability to rescue patients from harm.

Learning Objectives:
At the conclusion of this session, participants will be able to:
• Describe the role of human factors and resiliency engineering in system safety
• Identify recent advances and developments regarding human factors engineering and discuss their application to clinical practice.

Oren Guttman, MD, MBA

According to INS Infusion Therapy Standards of Practice, the organization establishes the process for compounding and preparing parenteral solutions and medications. There is a higher rate of error with IV medications compared to other routes. Sources of error include dilution of IV push medications, adherence to Aseptic Non Touch Technique (ANTT®) practices to reduce the risk of infection, drug shortages, and workflow changes—as well as the many steps involved in preparation and administration processes. Institute for Safe Medication Practices (ISMP) and INS recommend methods to reduce risk such as ready-to-administer (RTA) for IV push medications. In this session, we will discuss methods and training used to promote safe infusion medication preparation and administration.

Learning Objectives:

At the conclusion of this session, participants will be able to:
• List 3 common errors during preparation and administration of IV push medications
• Describe how to prepare an IV push medication following ANTT guidelines
• Discuss ways to enhance nurses’ role in proactively reducing IV push medication errors

​Maureen Burger MSN, RN, CPHQ, FACHE

Medication administration errors are among the most vexing and costly events in health care. A therapeutic infusion is intended to help the patient, but sadly patient harm through error can swiftly displace the intended therapeutic effect, which may result in disruption of therapeutic regimen, over- or underdosing leading to loss of intended therapeutic effect, debilitating injury, or even death. In 2020, the Institute for Safe Medication Practices (ISMP) published ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. Compiled and reviewed by many clinical experts, this resource outlines the components necessary for developing an organizational infrastructure that promotes safe patient care through the application of smart infusion pump technology. In this session, we will explore the interface between the infusion pump and the nurse (the interface between device and human) as well as the realm in which critical decisions are made and presumptive actions performed; and how successful or deleterious outcomes are initiated.

Learning Objectives:
At the conclusion of this session, participants will be able to:
• Describe the role of smart infusion pumps in optimizing medication safety during medication infusions
• Discuss the risks and benefits of using smart infusion pumps for medication administration
• Explain how to improve the utilization of smart infusion pump technology in the healthcare setting

Evan Frasure, PharmD, BCPS

Medical errors occur frequently in health care with lasting impacts for both the consumers and the health care professionals involved. The COVID-19 pandemic has created a sequela of events that have compounded existing stressors in the workplace which contribute to a propensity for error. When an error does occur, clinicians are often poorly supported, leading to detrimental impacts on their well-being and their ability to recover and grow following the event. These impacts have implications for systems learning, patient experience, and safety. Evidence from more than 20 years of research provides insights into strategies that can be applied by health care leaders, managers, and colleagues to respond proactively in order to optimize recovery and to implement constructive change following errors. In this session, attendees will learn about how making an error can impact clinicians and the approaches that can mitigate clinician suffering and promote individual and collective recovery.

Learning Objectives:
At the conclusion of this session, participants will be able to:
• Describe the impacts and sequalae of making a medical error on clinicians and patient care
• Discuss the strategies that support and follow-up following a medical error that contribute to constructive changes being made in practice
• Explain how healthcare leaders can best support those involved in a medical error to enhance well-being and care

Reema Harrison, PhD

In this session learners will shift the patient safety mindset from learning from and responding to error to more deeply understanding how teamwork is the foundation of safety. As we put the patient at the center of our care, we recognize the interconnectedness of the complex system in which care is delivered—the importance of the team. We will expand the conversation on infusion safety and the traditional Safety 1.0 thinking to the concept of Safety 2.0—understanding why things go right. Participants will recognize the power of teams in complex adaptive systems, take away specific skills to enhance teamwork, and be re-energized to continue making a positive impact in the lives of patients.

Learning Objectives:
At the conclusion of this session, learners will be able to:
• Describe the differences between Safety 1.0 and Safety 2.0 thinking
• Discuss the importance of shifting the patient safety mindset to learning why things go right using a patient story
• Explain specific strategies to enhance teamwork to support safety

Kara Lyven, MBA, CPPS