Systems Thinking and Medication Safety
Steve Peterson, BSN, RN-BC
Pharmacy Clinical Nurse Liaison Specialist
January 6, 2015
Objectives
• Provide a working definition of “systems thinking”
• Describe the influence connections and social networks
have in complex systems and systems thinking
• Describe fundamental concepts of complexity science and
complex adaptive systems
• Facilitate understanding of systems thinking concepts
related to medication administration through a
comparative illustration example
•
Describe the importance of systems thinking principles in safe
medication practices
The “Colorado Case”
(Smetzer, 1998)
Background
• Male infant born October 1996 near Denver,
Colorado
• penicillin G benzathine 50,000 units/Kg IM x 1
• penicillin G 50,000 units/Kg
The “Colorado Case”
• Processing the order
• Dispensing the medication
The “Colorado Case”
•
•
•
•
Processing the order
Dispensing the medication
Preparation for administration
Medication administration
The “Colorado Case”
•
•
•
•
Processing the order
Dispensing the medication
Preparation for administration
Medication administration
Processing the Order
• No pediatric pharmacist
• Pharmacist on duty unfamiliar with treatment of
CS; little knowledge of the medication (rarely
used, non-formulary)
• Reviewed the HD recommendation and
consulted Drug Facts and Comparisons
Processing the Order
• Misread dose in both as 500,000 units/Kg
• Misread physician's order as 1,500,000 units
• No warning when the dose entered into the
computer system
• Dose of 1.5 million units was prepared…
Dispensing the Medication
• 2 syringes; each syringe: Pen G benzathine 1.2
million units/2 mL with sticker: “Note dose
strength”. No other warning labels.
• To administer 2.5 mL IM (1,500,000 units)
– Correct dose: 0.25 mL (150,000 units)
Max IM Volume for Infant?
= 0.5 mL x 5 = 2.5 mL
= 0.25 mL (correct dose)
Dispensing the Medication
• The med in one of the syringes had expired,
so it was replaced
• Another pharmacist dispensed the med
without checking the original order…
Preparation for Administration
•
•
After noting the order, the bedside nurse and NNP researched treatment
for CS
1994 Red Book: Report of the Committee on Infectious Disease
•
•
•
Neofax ’95
•
•
•
•
Offered Pen G benzathine IM as option
Did not state “IM only”
Did not specifically mention PCN G benzathine, so no warnings for “IM only”
Aqueous crystalline PCN G slow IVP
NICU Medication Administration (no mention of PCN G benzathine)
Decided 5 IM injections was too many… decided to consider IV route
Preparation for Administration
• Hospital policy did not clearly define
prescriptive authority for non-physicians…
• NNP thought she was acting under a national
protocol that allowed her to plan, direct,
implement, and change drug therapy
Medication Administration
• Neither nurse noticed that the syringes were
labeled with a manufacturer’s warning: “IM use
only”
• Manufacturer warning was 180º away from drug
name
– Orange plunger in PF syringe concealed part of the
“M” in “IM”
Medication Administration
•
•
Both manufacturer and pharmacy labels expressed dose as
“1,200,000” instead of “1.2 million”
PCN G benzathine is white, milky substance
•
•
•
•
•
Same as lipids…
No additional concern
Began to give med via IVP…
After 1.8 mL the infant became unresponsive
Resuscitation efforts were unsuccessful
Who is to Blame???
•
•
•
•
•
Nurse?
Nurse practitioner?
Pharmacist?
Physician who wrote the order?
Staff who did not transcribe information
correctly?
• Physician who did not write ID physician
recommendations before event?
Who is to Blame???
Three nurses were indicted on charges
of negligent homicide
Over 50 systems errors attributable!
“To do things differently, we must see things
differently. When we see things we haven’t
noticed before, we can ask questions we didn’t
know to ask before.”
Who???
What!?!
- John Kelsch, Xerox
We Are Products of Our
Environments
Medication Safety
Five Rights:
1.
2.
3.
4.
5.
Right patient
Right drug
Right dose
Right route
Right time
Four More??
6. Right
documentation
7. Right action
8. Right form
9. Right response
(Elliott &Liu, 2010)
Importance of Systems Thinking in Safe
Medication Administration Practices
Safe medication practice involves
multiple “systems”, connecting numerous
individuals with varied influences
(positive or negative), throughout which
potential threats to process integrity and
patient safety must be considered at
each phase, up to and including final
administration.
Systems Thinking
“… understanding a system by examining the
linkages and interactions between the
components that comprise the entirety of the
defined system.”
(Institute for Systemic Leadership, 2014)
Systems Thinking
“… takes into account the structures, patterns of
interaction, events and organizational dynamics as
components of larger structures, helping to
anticipate rather than react to events, and to better
prepare for emerging challenges.”
(Atun, 2012, p iv5)
Connected
•
•
•
We don’t live in groups, we live in networks (p.214)
“Bucket Brigade” (pp. 214-215)
“Human Superorganism” (pp. 289-292)
•
•
•
Colony of ants
Cells in a multicellular organism
Social networks
•
•
•
Memory
Turnover
“Self-annealing”
(Christakis & Fowler, 2009)
Networks
HIGH Transitivity
LOW Transitivity
Connected
(Christakis & Fowler, 2009, pp 303-304)
Complexity Science
“… a collection of individual agents with freedom to act in ways
that are not always totally predictable, and whose actions are
interconnected so that one agent’s actions changes the context
for other agents” (Plsek & Greenhalgh, 2001, p 625).
“… a way of thinking, behaving, and approaching care” (Bleich,
2011, p 254).
Complex Adaptive Systems in
Healthcare
•
•
•
•
•
•
•
•
“Fuzzy” boundaries
Actions based on internalized rules
Agents and the system are adaptive
Systems are embedded within other systems
Tension and paradox are natural phenomena
Continually emerging, novel behavior
Inherent non-linearity
Inherent unpredictability
(Plsek & Greenhalgh, 2001)
Am I even in the right presentation?
I thought we were talking about Systems
Thinking… and what does this have to do
with medication administration???
Wait… it gets even better!
Illustrating the Concepts of Systems
Thinking and Medication
Administration in Terms of
Pathophysiological Aspects of Cellular
Responses to Injurious Agents
Oh, yes I did…
Pathophysiology
Systems Thinking
Environment
Environment
Body
Organization
Organ
Services
Tissue
Department/Unit
Cell
Staff
Organelle
Staff tasks
Material
Data
Weakening of the System
Atrophy (Cizaldo, 2010)
• Potential response to an
“injurious agent”
• Shrinkage of cells
• Due to loss of “cell
machinery”, not water
Workarounds (Med Admin)
• Potential response to
complex, time-consuming, or
overwhelming situations
• Deviation from Standard of
Care
• “Shrinkage” of tasks/duties
• Due to elimination of “steps”,
not knowledge/responsibility
Potential Causes
Atrophy (Cizaldo, 2010)
• Decreased blood supply
• Inadequate nutrition
• Change in hormonal
stimulation
• Loss of innervation
Workarounds (Med Admin)
• Reduction or inadequate
“flow” of necessary
components
• Decreased quality of essential
components
• Change in process stimulation
• Impaired communication
within network(s)
Results/Consequences
Atrophy (Cizaldo, 2010)
Workarounds (Med Admin)
•
Production of autophagic vacuoles
(lysosomes)
•
Production of “pockets” of “enzymatic
actions” within the process
•
Cell “machinery” reduced via autodigestion, due to decreased demand
•
Steps eliminated (Value vs Non-value)
•
“Remnants” or implications of the
workaround (modified practice,
reduced safety net, subtherapeutic vs
toxic administration)
•
Over time, bad habits and eliminated
processes accumulate… e.g. “swiss
cheese effect”
•
Some particles are not digested; not
removable (lipofuscin)
•
Accumulation of lipofuscin can be lifelong in some cells- esp. where cell
division/replication does not occur
“Injurious Agents”
When exposed to an injurious agent, the
cell/tissue will try to adapt to overcome the
agent.
However, if exposed long enough, then the
effects of the agent become too great, and there
will be permanent damage.
(Cizaldo, 2010)
Injurious Agents
Cell Pathophysiology (Cizaldo, 2010)
•
Hypoxia
•
Chemicals/Toxins/Poisons
•
Infectious agents (direct destruction, toxin
secretion, hypersensitivity reaction)
•
Immune response (over- or under-response)
•
Nutritional imbalances
•
Physical agents (abnormal temps, chemicals,
pressure, ionizing radiation, etc…)
Medication Administration
•
Lack of “rights of medication administration”
(How many??)
•
Barriers to critical thinking and/or “blocking”
the proper pathway or process
•
Task overload/underload, attitudes,
behaviors, practices, experience, and/or
personalities
•
System’s ability to compensate for threats
•
Lack of adequate resource materials; not
utilizing proper resources/references
•
Environment of care…
Barriers to Critical Thinking
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Frequent task switching and unpredictable demands
•
Heavy cognitive load with little uninterrupted time
•
Conditions necessary for critical thinking are rare
•
Similar to physician workflow research
•
Interventions:
•
Lean design
•
Duty reallocation/delegation
•
Technology deployment
•
Continuous education and training
(Cornell et al, 2011)
Swiss Cheese Effect
(Reason, 2010)
Systems Thinking… In Practice
“… careful consideration of potential consequences
of policies and actions, generating scenarios
through working and joint thinking: taking into
account the interactions between health system
elements and the context… (p. iv5).”
(Atun, 2012)
Summary
•
Systems Thinking  “Think globally, act locally”
•
Everything is connected… your influence transcends your immediate
actions
•
Complexity Science  1 + 2 ≠ 3 (Parts < Whole)… Expect the unexpected
•
Complex Adaptive Systems (Healthcare Environments) are unpredictable,
interconnected, adaptive, and always evolving…
•
“Injurious Agents” are numerous and always present a threat
•
A “reporting culture” helps to build system “immunity”
•
Medication administration is a critical component in patient care whereby
a patient can be healed or harmed. YOU are often the deciding factor...
Importance of Systems Thinking in Safe
Medication Administration Practices
Safe medication practice involves
multiple “systems”, connecting numerous
individuals with varied influences
(positive or negative), throughout which
potential threats to process integrity and
patient safety must be considered at
each phase, up to and including final
administration.
References
Atun, R. (2012). Health systems, systems thinking, and innovation. Health Policy and
Planning, 27, iv4-iv8. doi:10.1093/heapol/czs088
Bleich, M. (2011). Providing nursing care in a complex health care environment. In A. W.
Davidson, M. Ray, & M. Turkel, Nursing, Caring, and Complexity Science: For HumanEnvironment Well-Being (pp. 253-262). New York, New York: Springer Publishing
Company.
Christakis, N., & Fowler, J. (2009). Connected: The Surprising Power of Our Social
Networks and How They Shape Our Lives. New York, Ney York: Back Bay Books.
Cizaldo, G. (Performer). (2010). Biology 3020- Pathophysiology with Doc C. Duluth, MN.
Retrieved November 2014
Cornell, P., Riordan, M., Townsend-Gervis, M., & Mobley, R. (2011). Barriers to critical
thinking. Journal of Nursing Administration, 41(10), 407-414.
doi:10.1097/NNA.0b013e31822edd42
Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: an overview.
British Journal of Nursing, 19(5), 300-305.
References
Institute for Systemic Leadership. (2014). Basic principles of systems thinking as applied
to management and leadership. Retrieved November 2014, from The Institute for
Systemic Leadership: http://www.systemicleadershipinstitute.org/systemicleadership/theories/basic-principles-of-systems-thinking-as-applied-tomanagement-and-leadership-2/
Johnson, J., Barach, P., Cravero, J., Blike, G., Godfrey, M., Batalden, P., & Nelson, E. (2007).
Improving patient safety. In E. Nelson, P. Bataldan, & M. Godfrey, Quality By Design:
A Clinical Microsystems Approach (pp. 165-177). San Francisco, CA: Josey-Bass.
Plsek, P., & Greenhalgh, T. (2001). The challenge of complexity in health care. British
Medical Journal, 323, 625-628.
Reason, J. (2000). Human error: models and management. British Medical Journal, 320,
768-770.
Smetzer, J. (1998). Lesson from Colorado: beyond blaming individuals. Nursing98, 28(5),
48-51.
Questions?
Thank You
Steve Peterson, BSN, RN-BC
stpeters@stormontvail.org
354-6558