More than a decade ago, Bates and Gawande 1 published an article in the New England Journal of Medicine outlining the promise of information technology to enhance patient safety. They identified the potential for dramatic improvement in patient safety. However, much of the promise has not been realized. In this column, we use their framework as a launching point to discuss progress of specific technology integration into practice, identifying benefits of use, and implications for the role of the clinical nurse specialist (CNS).

Health information technology can be effective in preventing adverse events. Technologies that improve communication, provide point of care references, assist with calculations, perform monitoring functions, and provide decision support hold great potential in preventing harm. In the area of clinician communication, hand-offs have been identified as a critical touch point. There are several technologies available to facilitate effective hand-offs: wireless and remote access to the electronic health record (EHR), a computerized coverage system that facilitates effective sign-off, and standardized communication tools that provide a standardized template for information exchange.

Nursing studies exploring the impact of EHR documentation and communication have found the use of technology-guided documentation improved legibility, resulted in less errors, and reduced nursing overall documentation time. 2,3 Carrington and Effken 4 explored the strengths and limitations of EHR documentation of clinical events. Results from this study found that nurses used the EHR to retrieve and effectively communicate essential patient care information. A primary barrier to communication in this study was related to nurses reporting difficulty in using the technology at maximum efficiency. Another study by Effken and colleagues 5 found that EHR documentation by nurses could be used to identify communication patterns that impacted patient safety (eg, falls and medication errors) and quality measures (eg, symptom management, complex self-care, and patient satisfaction). A study focusing on the use of EHR during interprofessional rounds found increased efficiency in rounds, more accurate charting, and more consistent and complete communication processes. 6 While this study primarily focused on medical resident outcomes, the findings suggest the strategy could be used to more efficiently communicate essential rounds and clinical consultations by CNSs with frontline nurses. Improved communication can also occur when a clinician is notified of abnormal laboratory values in a timely and efficient manner. While accuracy of laboratory analysis and EHR interface has improved over the years, maximizing electronic alerts that are consistently meaningful to the clinician and avoid alert fatigue, however, remains a challenge. 7 The CNS can be instrumental in helping design laboratory value alert parameters that maximize timely response to abnormal laboratory value notification systems.

A second type of technology that facilitates prevention of adverse events is electronic reference material available at the point of care. Best practice guidelines and drug reference systems are 2 examples. Electronic health record systems can link in current best practice, hospital practice guidelines, and other resources to guide care. Technologies that provide decision support capabilities have potential to avoid adverse events. Computers may use algorithms or more complex neural networks to provide support to clinician decision making. A simple example could be the calculation of weight-based doses of medication. Another example is the identification of inappropriate orders based on patient characteristics (eg, allergies), or risk of interactions of drugs with other drugs, foods, and so on. Studies exploring computer order entry to include medication orders have found computer order entry improves overall accuracy of intended care ordered. 8,9

E-books are also often available through hospital purchase or libraries increasing access to current best evidence. Programs such as Micromedex 10 and Epocrates 11 increase access to information on both the EHR and personal data devices/phones. As the clinical expert, the CNS is in a prime position to recommend essential online resources to enhance the translation of evidence-based practice and overall patient safety.

A third type of technology to avoid adverse events is a tool to assist with calculations, require specific data elements to be entered, and provide dosing guardrails for medication administration safety. Smart pump technology, also called intelligent infusion devices, contain software used to create medication libraries that facilitate safe medication delivery systems. The smart pump libraries inform the nurse of acceptable medication concentrations and dosing limits and provide clinical advisories. 12 Interprofessional collaboration of the pharmacist and nurse experts is necessary to develop robust medication libraries. In addition, most smart pumps provide data about medication administration practices. The CNS can use these data to review current practice, monitor practice outcomes, and address potential gaps in medication delivery systems. 12

A fourth technology, monitoring, allows for analysis of relationships and trends over time through use of algorithms. Use of technology tools for monitoring facilitates more effective use of clinician skills and removes human error. Current evidence has found that implementation of health information technology reduces errors, assists with diagnosis, and allows for more meaningful incorporation of evidence-based protocols to be accessible in guiding care decisions. 13 Similarly, tele–intensive care unit remote monitoring systems provide an additional layer of support for critically ill patients and inform providers with real-time information for clinical decisions that optimally influence patient care. 14 Once again, the clinical expert, CNS, is essential in leading the development of monitoring algorithms and implementation and outcome monitoring of technology-based monitoring systems.

Technological changes are occurring rapidly across various sectors in society. The use of technological innovations in healthcare to improve patient safety remains a challenge. Technologic advances can augment care as well as hinder care through nuisance alarms and meaningless alerts. 15 It is important for practice environments to have clinical experts, the CNSs, inform the technology-based practice decisions to maximize patient safety.

References

1. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003; 348: 2526–2534. Check Document Availability Bibliographic Links [Context Link]

2. Smith K, Smith V, Krugman M, Oman K. Evaluating the impact of computerized clinical documentation. Comput Inform Nurs. 2005; 23( 5): 128–132. [Context Link]

3. Nahm R, Poston I. Measurement of the effects of an integrated point of care computer system on quality of nursing documentation and patient satisfaction. Comput Nurs. 2000; 18( 5): 247–249. [Context Link]

4. Carrington JM, Effken JA. Strengths and limitations of the electronic health record for documenting clinical events. Comput Inform Nurs. 2011; 29( 6): 360–367. [Context Link]

5. Effken JA, Carley KM, Gephart S, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Med Inform. 2011; 80; 507–517. [Context Link]

6. Wohlauer MV, Rove KO, Pshak TJ, et al. The computerized rounding report: implementation of a model system to support transitions of care. J Surg Res. 2012; 172: 11–17. Check Document Availability Bibliographic Links [Context Link]

7. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010; 123( 3): 238–244. [Context Link]

8. Weir CR, Staggers N, Laukert T. Reviewing the impact of computerized provider order entry on clinical outcomes: the quality of systematic reviews. Int J Med Inform. 2012; 81: 219–231. Check Document Availability Bibliographic Links [Context Link]

9. Gillaizeau F, Chan E, Trinquart L, et al. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev. 2013;(11):CD002894. [Context Link]

10. Micromedex. http://micromedex.com/</