• adverse event
• Agency for Healthcare Research and Quality (AHRQ)
• alarm fatigue
• application (app)
• barcode medication administration (BCMA)
• clinical decision support (CDS)
• computerized provider order entry (CPOE)
• electronic medication administration system (eMAR)
• failure modes and effects analysis (FMEA)
• Government Accountability Office (GAO)
• high-hazard drug
• human factors engineering
• interdisciplinary collaboration
• interprofessional collaboration
• just culture
• never event
• radio-frequency identification (RFID)
• root-cause analysis
• safety culture
• sentinel event
• smart pump
• smart room
• systems engineering
• wearable technology
• workaround

Nursing professionals have an ethical duty to ensure patient safety. According to Lavin et al. (2015), “Direct care nurses, at their core, are risk managers. They attach meaning to what is and anticipate ‘what might be'” (para. 8). As the media and patients circulate stories about the lack of safety in healthcare institutions, it is no wonder that healthcare consumers are skeptical and providers are wary. A study out of Johns Hopkins University (McMains, 2016) suggested that medical errors are the third-leading cause of death in the United States. Versel (2016) reminded us, however, that “it's not the first time someone has called medical error the No. 3 cause of death in the U.S. John T. James, founder of a group called Patient Safety America, did that in a 2013 report in the Journal of Patient Safety” (para. 2). The World Health Organization (2019) offered this perspective: “It is estimated that there is a 1 in 3 million risk of dying while travelling by airplane. In comparison, the risk of patient death occurring due to a preventable medical accident, while receiving health care, is estimated to be 1 in 300” (para. 1). In 2022, Wilsonlaw.com outlined 10 medical errors that can lead to patient deaths, many of which can be addressed by informatics and technology. They include communication issues, information flow issues, medication errors, poor organizational transfer of knowledge, misdiagnosis, delayed diagnosis, patient identification and assessment issues, staffing and workflow issues, medical equipment malfunctions, and inadequate organizational policies.

Increasing demands on professionals in complex and fast-paced healthcare environments may lead them to cut corners or develop workarounds that deviate from accepted and expected practice protocols. These deviations are not carried out deliberately to put patients at risk but rather are often practiced in the interest of saving time or preserving a usual workflow or because the organizational culture is such that risky behaviors are commonplace. Occasionally, these inappropriate actions or omissions of appropriate actions result in harm or significant risk of harm to patients. The Patient Safety Network (2022) outlined the issues created by the COVID-19 pandemic and emphasized the additional safety risks for both patients and healthcare workers. During infection surges, we faced shortages of ventilators, catheters, and personal protective equipment (PPE) supplies. Typical unit workflows, staffing (staff were infected), and communication (wearing PPE) were disrupted. In addition, ventilated patients were placed in the prone position to support lung function, and skin integrity was compromised in unusual places. Some patients also developed additional infections while hospitalized, which further compromised their illness trajectory. “As more data become available, highlighting where innovative approaches were successful at reducing the risk of adverse events during the pandemic, researchers and policymakers will need to determine if there are particular best practices that may be suitable for continued use beyond the pandemic” (para. 9).

A safety issue that results in death, permanent harm, or serious temporary harm that requires intervention is termed a sentinel event by the Joint Commission (n.d.). In 2013, the sentinel event definition was expanded to include safety issues involving anyone on the institution's premises (Patra & De Jesus, 2022). Consider the following case scenario:

The 2000 Institute of Medicine's report To Err Is Human is widely credited for launching the current focus on patient safety in health care. This report was followed in 2001 by the Institute of Medicine's report Crossing the Quality Chasm, which brought to national attention healthcare quality and safety. This national attention resulted in a $50 million grant by Congress to the Agency for Healthcare Research and Quality (AHRQ) to launch initiatives focused on safety research for patients. Other initiatives prompted by these seminal reports were the Joint Commission's National Patient Safety Goals (updated yearly since 2002), the National Quality Forum's adverse events and never events list (2002), the creation of the Office of the National Coordinator for Health Information Technology (ONC) to computerize health care (2004), the formation of the World Health Organization's Alliance for Patient Safety (2004), the Institute for Healthcare Improvement's (IHI's) 100,000 Lives campaign (2005) and 5 Million Lives campaign (2008), congressional authorization of patient safety organizations created by the Patient Safety and Quality Improvement Act to promote blameless error reporting and shared learning (2005), the “no pay for errors” initiative launched by Medicare (2008), and the $19 billion congressional appropriation to support electronic health records (EHRs) and patient safety (Wachter, 2010). In 2013, the Patient Safety Movement Foundation launched the Open Data Pledge and later announced three new patient safety challenges in 2016 (Patient Safety Movement, 2016). The most pressing challenges it identified-venous thromboembolism, mental health, and pediatric adverse drug events-reflect those in which patient death could be prevented with the proper protocols in place during the provision of patient care.

The AHRQ (2019) safety culture primer suggested that organizations should strive to achieve high reliability by being committed to improving healthcare quality and preventing medical errors and demonstrating an overall commitment to patient safety; that is, everyone and every level in an organization must embrace the safety culture. Key features of a safety culture identified by the AHRQ are as follows:

• Acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
• A blame-free environment where individuals can report errors or near misses without fear of reprimand or punishment
• Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
• Organizational commitment of resources to address safety concerns (para. 1)

The Committee on Patient Safety and Education of the American Society of Anesthesiologists (2022) emphasized that “[o]rganizations with strong safety cultures are not characterized by a complete absence of adverse events, but by their commitment to capturing and responding to these events, recognizing how each one gives valuable insight for further system improvement. Unsafe cultures, in contrast, can be highlighted by a lack of trust, fear of speaking up, absence of transparency, incivility, or even workplace violence” (para. 2).

An important part of the safety culture is cultivating a blame-free environment. Errors and near misses must always be reported so that they can be thoroughly analyzed to ascertain changes needed to prevent reoccurrence. All organizations can learn from mistakes and change their organizational processes or culture to ensure patient safety. These critical points are reiterated in a recent Sentinel Event Alert released by the Joint Commission (2018). The Patient Safety and Quality Improvement Act of 2005 mandated the creation of a national database of medical errors and funded several organizations to analyze these data with the goal of developing shared learning to prevent medical errors. Organizations themselves can engage in root-cause analysis or failure modes and effects analysis (FMEA), both of which are systems analyses to examine medical errors closely to determine the system processes that need to be changed to prevent similar future errors (Harrison & Daly, 2009; Patient Safety Network, 2019c). A tool for implementing root-cause analysis, which was developed by the U.S. Department of Veteran's Affairs National Center for Patient Safety (n.d.), had three goals: to determine “what happened, why did it happen and how to prevent it from happening again” (para. 4). Everyone is encouraged to submit actual medical errors and/or patient safety issues to the Patient Safety Network (n.d.). Similarly, the IHI has a website dedicated to FMEA. “Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change” (IHI, n.d.-b, para. 1). This powerful tool can be viewed at www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisTool.aspx. The discussion accompanying the systems approach advocated by the Patient Safety Network (2019c) emphasized “that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations)” (para. 2).

If one embraces a blame-free environment to encourage error reporting, then where does individual accountability fit in? According to the AHRQ (2019), one way to balance these competing cultural values (blameless vs. accountability) is to establish a just culture in which system or process issues that lead to unsafe behaviors and errors are addressed by changing practices or workflow processes and a clear message is communicated that reckless behaviors are not tolerated. The just culture approach accounts for three types of behaviors that lead to patient safety compromises: (1) human error (i.e., unintentional mistakes), (2) risky behaviors (i.e., workarounds), and (3) reckless behavior (i.e., total disregard for established policies and procedures). The Joint Commission (2018) indicated that to encourage reporting in a just culture, leadership must use accountability assessment tools to distinguish between human error and reckless behavior: “Leadership must gradually change the culture so that the need to report and do something about a safety issue outweighs the fear of being punished” (para. 11).

Strategies for achieving a safety culture have been addressed frequently in the literature and embraced by several key organizations. The focus here is limited to those strategies described by three key organizations: the AHRQ, the Joint Commission, and the IHI. The AHRQ (2016), based on data from the Hospital Survey on Patient Safety Culture, suggested that teamwork training, executive walk-arounds, and unit-based safety teams have improved safety culture perceptions but have not led to a significant reduction in error rates. The AHRQ recommended seven steps for action planning: “1. Understand your survey results. 2. Communicate and discuss survey results. 3. Develop focused action plans. 4. Communicate action plans and deliverables. 5. Implement action plans. 6. Track progress and evaluate impact. 7. Share what works” (p. 61). Informatics can assist with the analysis, trending, synthesis, and dissemination of the action plan results. In 2020, the AHRQ released a report titled “Making Healthcare Safer III.” In this report, 47 patient safety practices in high-risk healthcare areas were reviewed, using a conceptual framework that “(1) puts the patient in the center; (2) acknowledges that patients are constantly exposed to potential harms; and (3) proposes patient safety approaches that mitigate patients' past and future vulnerabilities” (para. 3). Access an overview of the report here and then follow links to specific safety topics: www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goals/. The IHI (n.d.-a) stressed that organizational leaders must drive the culture change by making a visible commitment to safety and enabling staff to share safety information openly. Some of the strategies suggested by the IHI include appointing a safety champion for every unit, creating an adverse event response team, and reenacting or simulating adverse events to better understand the organizational or procedural processes that failed. The IHI (Frankel et al., 2017) released a white paper titled “A Framework for Safe, Reliable, and Effective Care,” which emphasized the organizational culture, the need to establish a learning system, and patient engagement as cornerstones of safety. Access the paper here: www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx.

Leadership oversight and support are critical to ongoing sharing about errors; near misses; and, most importantly, collaborative solution development to provide safe care and achieve quality outcomes for all patients. Radick (2016) believed that senior leaders must be involved to sustain patient safety improvements. The importance of leadership in a safety culture was emphasized by the Joint Commission (2018). Leaders understand “that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes” (para. 1). In the same Sentinel Event Alert, three characteristics of a safety culture were emphasized:

• Just culture: People are encouraged, even rewarded, for providing essential safety-related information, but clear lines are drawn between human error and at-risk or reckless behaviors.
• Reporting culture: People report their errors and near misses.
• Learning culture: People are willing and competent to draw the right conclusions from safety information systems and willing to implement major reforms when their need is indicated.

Ways must be found to encourage people to report errors, near misses, and good catches so that systems and processes can be reviewed and improved and people can learn from errors. Carmack and Valleru (2022) emphasized the importance of speaking up when a safety concern or issue is observed. “The act of speaking up is not automatic; it will occur when there is intentional support from nursing leaders and medical staff members to remove barriers and enhance trust, which is critical for success with speaking up and stopping the line for safety” (p. 352).

Each year, the Joint Commission releases Hospital National Patient Safety Goals. The 2023 goals center around patient identification, staff communications, medication use, alarms, infection prevention, identifying patients at risk for suicide, and prevention of surgical mistakes. Access the 2023 version at this site: www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/2023-hap-npsg-goals-102122_simple.pdf. For a comprehensive look at global strategies for safety in health care, access the World Health Organization's Global Patient Safety Action Plan 2021-2030: www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan. The safety literature is clearly converging to emphasize culture, reporting, patient and family engagement, and learning.

We turn now to safety initiatives more specifically related to technology. A systems engineering approach to patient safety, in which technology manufacturers partner with organizations to identify risks to patient safety and promote safe technology integration, was advocated by Ebben et al. as early as 2008. They noted that human factors engineering is “[t]he discipline of applying what is known about human capabilities and limitations to the design of products, processes, systems, and work environments” and its application to system design improves “ease of use, system performance and reliability, and user satisfaction, while reducing operational errors, operator stress, training requirements, user fatigue, and product liability” (p. 327). For example, Ebben et al. described the feel of an oxygen control knob that rotated smoothly between settings, which suggested to the user that oxygen flows at all points on the knob, when in fact oxygen flowed only at specifically designated liter flow settings. Human factors engineering testing would most likely reveal this design flaw, and the setting knob could be improved to include discrete audio or tactile feedback (click into place) to the user to indicate a point on the dial where oxygen flows. Ebben et al. also emphasized that testing human use factors provides more objective safety data than the subjective responses gained from user preference testing. “Understanding how the equipment shapes human performance is as important as evaluating reliability or other technical criteria” (p. 329). A World Health Organization (2016) publication makes an important point about human factors engineering: “The overall human factors philosophy is that the system should be designed to support the work of people, rather than designing systems to which people must adapt” (p. 5). Further, this publication cautions that issues with information and information chaos contribute to safety incidents because clinicians are overwhelmed with information. It defined information chaos as follows:

• Information overload (i.e., too much unnecessary information)
• Information underload (i.e., missing or not enough information)
• Information scatter (i.e., information located in many different places and difficult to find)
• Erroneous or conflicting information (p. 6)

Organizations that are purchasing medical technology devices should avail themselves of shared safety data on equipment maintained by several key organizations, including the Joint Commission, the U.S. Food and Drug Administration (FDA), and the Medical Product Safety Network (www.fda.gov/medical-devices/medical-device-safety/medsun-medical-product-safety-network). Many healthcare practitioners feel that we have not made great strides in either sharing our data or accessing the available data to enhance patient safety interests. According to the WISH Patient Safety Forum (Pronovost et al., 2015), the patient safety premises that harms are inevitable, data silos (rather than shared data) are natural, and heroism is the norm “have inadvertently provided excuses for not addressing patient safety comprehensively” (p. 9). This forum also stated the following:

The belief that data silos are acceptable in healthcare settings is an irresponsible view regarding the role of data; it lacks an understanding of the current operational setting. Healthcare is a complex, multidisciplinary environment that requires collaboration and sharing of data across an integrated stakeholder community. (p. 9)

As health information technology (IT) evolves and is refined, it continues to improve patient safety. Banger and Graber (2015) stated the following:

ONC is involved in a number of initiatives in support of this goal, including plans for a new national Health IT Safety Center to coordinate these efforts. Combined with the active engagement from the private sector, there is every reason to be optimistic that health IT will continue to improve the quality and safety of health care beyond the accomplishments realized to date. (p. 10)

According to the Patient Safety Network (2019b), “busy health care workers rely on equipment to carry out life-saving interventions, with the underlying assumption that technology will improve outcomes” (para. 2). The Patient Safety Network provided the following descriptions of equipment issues:

An obstetric nurse connects a bag of pain medication intended for an epidural catheter to the mother's intravenous (IV) line, resulting in a fatal cardiac arrest. Newborns in a neonatal intensive care unit are given full-dose heparin instead of low-dose flushes, leading to three deaths from intracranial bleeding. An elderly man experiences cardiac arrest while hospitalized, but when the code blue team arrives, they are unable to administer a potentially life-saving shock because the defibrillator pads and the defibrillator itself cannot be physically connected. (para. 1)

Once the technology is integrated into the organization, biomedical engineers can become valuable partners in promoting patient safety through appropriate use of these technologies (Figure 15-1). For example, in one organization, the biomedical engineers helped to revamp processes associated with the new technology alarm systems after they discovered several key issues: slow response times to legitimate alarms and multiple false alarms (promoting alarm fatigue) created by alarm parameters that were too sensitive. Strategies for addressing these issues included improving the nurse call system by adding Voice over Internet Protocol telephones, which wirelessly receive alarms directly from technology equipment carried by all nurses, thus reducing response times to alarms; feeding alarm data into a reporting database for further analysis; and encouraging nurses to round with physicians to provide input into alarm parameters that were too sensitive and generating multiple false alarms (Joint Commission, 2013; Schlabig Williams, 2009).

Figure 15-1 User-Technology-Patient Safety Scheme

A three-part illustration outlines the user-technology-patient safety scheme.

In the first section, three circles overlap to represent the user, encompassing patient or guardian or caregiver, healthcare provider, and ancillary personnel. The second part focuses on health information technology, H I T, with four overlapping circles indicating developer, user or healthcare provider, researcher, and I T personnel. These components lead to a flow diagram of patient safety, emphasizing criteria such as the absence of data entry errors, timely data delivery, intact and complete data with no missing data, appropriate use of default values, exclusive electronic system utilization for patient care, integrity of patient data, that is, data associated with the correct patient, and capturing the latest information for reporting.

The case scenario, Well-Intentioned Providers, demonstrates how well-intentioned healthcare providers can cause harm. An audit conducted by Philips Healthcare (2013) at one of its customer sites revealed the following:

[A] Telemetry Charge Nurse was found to be receiving and responding to an average of 3.7 alarms per minute over the duration of the audit. Even allowing for minimal time to respond to each alarm, it is clear that this situation was problematic. A majority of that nurse's time was spent responding to alarms, and inevitably some were missed. (para. 1)

Goal 4 of the 2023 Hospital National Patient Safety Goals of the Joint Commission is “Make improvements to ensure that alarms on medical equipment are heard and responded to on time” (para. 4). Interestingly, this goal first appeared in the 2014 edition and has been included every year since then. Many patient monitoring and medication administration technologies are equipped with alarms to alert caregivers of potential problems. At issue is the number of alarms, especially false alarms caused, for example, by artifact or patient movement. Multiple false alarms can lead caregivers to become desensitized so that they ignore or even turn off alarm systems. Some strategies suggested by the Joint Commission include developing policies and procedures to establish who can set or change alarm parameters, when an alarm can be disabled, and who is responsible for responding to alarms.

Case Scenario: Well-Intentioned Providers

Even well-intentioned healthcare providers can cause harm. Consider what should have been done differently in the following case scenario. Laura, a 25-year-old woman, arrived at the ER complaining of chest pain. She has two young children at home, a 6-year-old boy and a 4-year-old girl. She stated that she has been experiencing severe fatigue and fluttering in her chest for weeks but felt that she needed rest and it was probably nothing. Today, she had the fluttering with chest pain, and even her teeth and jaw hurt. This scared her, so she decided to go to the hospital. However, she had to wait 2 hours for her mother to arrive to watch the children. Her husband is on a business trip and will not be returning for 4 days. The initial ECG revealed normal sinus rhythm, and all lab values were normal. The emergency room physician decided to keep her for observation and sent her to the telemetry unit. Laura was moved to telemetry and, as she stated, “wired for sound.” The nurse described the equipment and told her that in addition to all of the monitoring equipment, they would check her vital signs every hour as well. The nurse no sooner returned to the nurse's station when Laura's cardiac monitor alerted her that Laura was experiencing severe bradycardia (i.e., heart rate of less than 40 beats per minute). When the nurse arrived at Laura's bedside, she found Laura sound asleep. She woke her gently and told her that her monitor was alarming and that she was going to check her. Laura stated that she felt tired and was enjoying the peaceful sleep. Laura's vital signs were fine and her heart rate was 72 beats per minute. The nurse reset the monitor, by which point Laura had already fallen back to sleep. The monitor alarmed the same way three more times within the next hour. Each time, the nurse woke Laura and everything was fine. The nurse decided to contact the resident. While she was waiting for the resident, it alarmed twice again, but she just reset it and let Laura sleep. The resident came and examined Laura. The resident felt everything was OK and that this young mother needed her rest. The resident suggested that the nurse stop the hourly vitals; call and have the equipment examined by the biomedical department; and, in the meantime, turn the alarm off. The nurse agreed, turned off the alarm, placed a call to the biomedical technician on duty, and left a message. The nurse had another patient who also had frequent alarms, but his corresponded to actual medical events. As a result, the nurse was spending a great deal of time with this elderly gentleman and his wife. Each time she walked by Laura's bed, the nurse noted that Laura was sleeping. She realized that it had been 2 hours since she had turned off the alarm and called the biomedical technician, so she decided to check on Laura; however, her other patient's alarm went off, and since Laura was sleeping, the nurse went to the other patient's bedside. At 4 hours after the alarm had been turned off, the biomedical technician arrived and apologized because one of the other techs called off sick in their department and they were shorthanded. The nurse explained what had happened, and the biomedical technician went to check Laura's monitoring equipment. The biomedical technician called for the nurse because the patient was unresponsive. The nurse could not wake Laura, and the monitor was showing asystole. A code was initiated, and Laura was pronounced dead 5 hours after she had arrived on the telemetry unit. This situation was assessed by the patient safety officer and the patient safety committee. Their determination was that because the monitor was integrated and all functions ran through the same controller, the nurse did not realize she was turning off all of the monitors (e.g., pulse oximetry and blood pressure). This situation was found to be an issue with the equipment itself because the alarm settings are too close together and not clearly labeled; however, the nurse should never have turned the alarms off. With the hourly checks canceled and all the monitoring equipment silenced, Laura was not being monitored at all. Well-intentioned providers were allowing this young mother to sleep but with fatal consequences.

It is evident from the case scenario that we have yet to find a solution to the problem of alarm fatigue and related issues that negatively affect patient safety.

Clearly, there is more work to be done to create safety cultures in complex healthcare organizations and to reduce the incidence of errors. Many organizations are looking to informatics technology to help manage these complex safety issues by using smart technologies that provide knowledge access to users and automated safety checks and that improve communication processes. Harrison (2016) stated that “as nurse leaders in a clinical setting where smart tools are leveraged to increase the quality and safety of patient care, we have certain responsibilities to ensure safe implementation, training, and monitoring” (p. 21). To best utilize the available technology, nurse leaders and administrators must be able to use data. More and more graduate programs for nursing administrators are realizing the need for these emerging nursing leaders to be skilled in nursing informatics. These leaders must be able to use data, information, and knowledge efficiently and effectively to assess and manage their clinical settings and, ultimately, to apply these informatics skills to improve patient outcomes and the quality of patient care (Figure 15-2).

Figure 15-2 Data and Quality Connection: There are many ways to obtain data and information. The skill is in knowing how to access, select, and use the data and information, applying nursing informatics to inform practice and improve patient care.

A team of healthcare professionals uses shovels to dig up a lawn for planting plants. A team of healthcare professionals uses garden trowels to dig up a lawn for planting plants. A group of healthcare professionals utilizing garden trowels to unearth a lawn for planting plants serves as a metaphor for their efforts in excavating data and information. A healthcare professional tends to an elderly patient. A healthcare professional tends to a pediatric patient in the presence of the caregiver.

In 2016, the Government Accountability Office (GAO) selected and assessed six hospitals, from which it identified three challenges in implementing patient safety practices. The number one challenge was “obtaining data to identify adverse reactions in their own hospitals” (para. 2). Nursing informatics skills and knowledge can address this challenge.

The GAO interviewed patient safety experts and reviewed the related literature to identify three key gaps where better information could help guide hospital officials in their continued efforts to implement patient safety practices. These gaps involve a lack of “(1) information about the effect of contextual factors on implementation of patient safety practices, (2) sufficiently detailed information on the experience of hospitals that have previously used specific patient safety implementation strategies, and (3) valid and accurate measurement of how frequently certain adverse events occur” (p. 22). It is clear that implementing solid nursing informatics practices, skills, and knowledge can close these gaps.

Healthcare technologies are frequently designed to improve patient safety, streamline work processes, and improve the quality and outcomes of healthcare delivery. As we continue to look to health IT to advance patient safety initiatives, we must realize that integrating health IT presents other challenges and can add to patient safety issues. For example, Singh and Sittig (2015) stated that health IT has the “potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety” (p. 226).

Although technology may certainly help to prevent or reduce errors, one must always remember that technology is not a substitution for safety vigilance by the healthcare team in a safety culture. Harrison (2016) stated that “[p]atient safety should always be at the center of the design and adoption of any technology introduced into patient care settings. Technology that's designed to improve patient safety is only as good as the person using the device. It doesn't replace critical thinking, solid nursing practice, and careful patient monitoring” (p. 21).

The Wired for Health Care Quality Act of 2005 began a series of funding streams to promote health IT and sharing of its best practices and to help organizations implement health IT (Harrison & Daly, 2009). Many early adopters opted to focus technology and safety initiatives on medication ordering and administration processes. Medication errors are the most frequent and visible errors because the medication administration cycle has many poorly designed work processes with several opportunities for human error. Thus, computerized provider order entry (CPOE), automated dispensing machines, smart pump technologies for IV drug administration, and barcode medication administration (BCMA) frequently preceded the adoption of the EHR in many institutions because of the comparatively lower costs associated with implementing these technologies. In an ideal world, the EHR would be adopted concurrently as part of an interoperable health IT system. In the early EHR systems, clinicians were prompted by electronic alerts to remind them of important interventions that should be part of the standard of care, but these alerts tended to be generalized and not patient specific-for example, “Did you check the allergy profile?” or “Has the patient received a pneumonia immunization?” These early alert and care reminders are now evolving into more sophisticated clinical decision support (CDS) systems to promote accurate medical diagnoses and to suggest appropriate evidence-based medical and nursing interventions based on patient data.

With the addition of triggers to detect adverse events, diagnostic errors, adverse drug events, hospital-acquired infections, and delays in diagnoses have been identified. In addition to the National Patient Safety Goals issued by the Joint Commission, which reference general safety hazards, other safety organizations and institutes provide information on top safety concerns. Cheney (2019) reported on the list of top 10 medical technology hazards of 2020 identified by the ECRI. The ECRI was founded in 1968 as the Emergency Care Research Institute and designated by HHS in 2008 as a Patient Safety Organization; in 2020, it affiliated with the Institute for Safe Medication Practices and was rebranded as ECRI, “the most trusted voice in healthcare” (ECRI, n.d.). The medical technology hazards identified by the ECRI were as follows:

1. Surgical staplers-staple line failures or misapplication
2. Point-of-care ultrasound-issues with user training, documentation and data archiving
3. Infection risks from sterile processing-especially in medical and dental offices and ambulatory settings
4. Hemodialysis risks with central venous catheters in the home health setting-risks include infection, clotting or hemorrhage
5. Surgical robotic procedures-limited tactile feedback for forces exerted on tissue may result in injury
6. Alarm, alert, and notification overload-numerous alarms may cause a clinically significant issue to be missed
7. Cybersecurity risks in the home health setting-increased vulnerabilities associated with remote monitoring and network connected medical technologies
8. Missing implant data for MRI scan patients-implants can heat, move or malfunction when exposed to MRI's magnetic field
9. Medication errors from dose timing discrepancies in electronic medical records-discrepancies between dose timing intended by the provider and nursing workflow
10. Loose nuts and bolts in medical devices-devices can tip, fall or collapse if not properly maintained (Cheney, 2019, para. 7)

Many of these issues can be prevented or detected in their early stages using informatics technologies, although we do see continued struggles with the same safety issues over several years. Other technologies designed specifically to promote patient safety include wireless technologies for patient monitoring, clinician alerts, point-of-care applications, apps, and radio-frequency identification applications. Each of these technologies is reviewed here, and the chapter concludes with a section that discusses future technologies for patient safety.

The human side of patient safety is paramount. As technologies that can help to reduce errors and increase safety are integrated into caregiving activities, healthcare professionals must also improve their ability to properly use and manage these technologies. Therefore, not only must the technology be scrutinized and tested routinely but also the users must be maintained and nurtured so that they are able to use the tools to the patient's benefit, avoiding harm and keeping the patient safe. Even the best CDS systems can contribute to mistakes by providing meaningless, outdated, or harmful information. Nurse informaticists and the IT team in the facility must ensure that all systems are properly configured and maintained. They should routinely monitor and check these systems while making sure that their users can use the systems accurately to avoid errors. A technology and its user can never be left to their own devices.

As we continue to apply informatics to patient safety, data warehousing and mining, reporting, data trending, and predictive modeling will enhance our ability to improve patient safety and provide quality health care. To gather the data and information necessary to analyze safety issues, monitoring systems, software, and hardware will continue to evolve. Risk monitoring and incident reporting software (i.e., reporting software specifically generating reports regarding incidents only), patient response monitoring systems, trending and predictive models, and reporting software will provide enhanced data and information to be analyzed.

Human inputting activities must focus on patient safety to raise the appropriate issues and sound out solutions. Nurse informaticists must be involved in all stages of the system development life cycle as new technologies are introduced while maintaining a focus on safety. Safety concerns and remedies need to be analyzed, synthesized, and integrated throughout the system development life cycle to have a robust tool that provides meaningful information and enhances patient care while preventing errors and promoting patient safety. Nurse informaticists can bridge the gap between IT staff, electronic systems designed to ensure patient safety, and nurses who are system users by attending to the disruptions inherent in technology implementation and promoting the best and safest uses of the systems. The Research Brief describes the results of a 2020 Healthcare Information and Management Systems Society (HIMSS) survey on the effect of nurse informaticists on patient safety. This survey is conducted every 3 years, so stay tuned for the 2023 results.

Interdisciplinary collaboration and interprofessional collaboration are terms used to describe cooperative relationships among actively engaged professionals where healthcare decision-making is shared to combine their collective knowledge and skills to care for their patients. All the professionals are working toward the same goal: positive patient outcomes. Interprofessional collaboration is crucial when caring for patients because the open exchange of ideas, experience, and knowledge helps the professionals develop a comprehensive plan of care.

It is important for educators and administrators to realize the potential for preparing collaborators by developing a collaborative approach and interprofessional educational activities and opportunities. Successful interprofessional collaborative education experiences will foster a willingness to participate in interprofessional collaboration efforts on behalf of patients. Refer to the website of the Centre for the Advancement of Interprofessional Education (CAIPE) for information on the principles, values, processes, and outcomes of interprofessional education: www.caipe.org/about.

Informaticists must recognize their position on the team to promote interprofessional collaboration; so, too, each professional must appreciate that they are part of an interprofessional team and are obligated to collaborate with the other team members for the patient's best interests to provide quality care to every patient. Informaticists must be willing to share, communicate, and deliberate with other professionals caring for the same patient to achieve the best outcomes for the patient. All healthcare professionals must work together to enhance quality and to secure the most positive outcomes for each and every patient treated.

The informaticist can facilitate interprofessional collaboration to improve patient care by enhancing the capability for sharing data and information in both synchronous and asynchronous formats. Therefore, the informaticist's role is critical to facilitate data, information, and knowledge exchange in a safe and secure environment that affords professionals connectivity, access, and confidence in their ability to collaborate.

Patient safety is an important and ubiquitous issue in health care. This chapter explored the characteristics of a safety culture and technologies designed to promote patient safety. The need to evaluate errors carefully to determine why and how they occurred and how workflow processes might be changed to prevent future errors of the same type was emphasized. Technology is changing rapidly, and the culture of sharing related to technology implementation, error reporting, and troubleshooting should prompt continuous process improvements. The key for organizations is to invest in their users and to choose wisely so that the technologies they are adopting will not negatively affect safety and will be interoperable and easily upgradable as technologies and safety practices evolve.

Organizations must make a commitment to a safety culture in which everyone at every level is committed to patient safety at every moment. In an ideal world, everyone would first stop and think “Is this safe?” before every action, workarounds would not occur, and everyone would embrace the technologies and workflow processes designed to promote patient safety. Table 15-1 provides a list of websites to consult for updates on patient safety technologies. The nurse informaticists, healthcare providers, patients, ancillary team members, administrators, settings/environments, infrastructures, and technologies must all work together to create a safety culture. Every organization must provide safe, quality health care and prevent harm or adverse events for every patient under its care by ensuring that patient safety is critical to the organization's mission.