Health IT in Healthcare Organizations questions

Purpose

• To answer questions about key points in the Digital Doctor reading assignment, which will help students stay engaged with the content throughout the reading.
• To review the case study laid out in the book, which illustrates the complexity of errors that commonly happen in healthcare and how each of the key players play a role in that error.

To complete the assignment and answer the questions below. Do the following:

1.Read: The Digital Doctor (Wachter, 2015) PDF, Read Chapters 12-19

2.Read: Lecture PowerPoint (HIT Organizations)

3. Watch: Lecture Videos

For each question, please include details from each chapter to demonstrate that you read and understood the content.

The summary should be in your own words - Do not directly copy/paste from the book chapters; Also, limit your use of "direct quotes" unless it is very important in your answer to use the exact words.

 Question 1

Question 1

CHAPTER 12 - THE ERROR = What was "the error" that is described in this chapter?

Remember to provide details that demonstrate your review and understanding of the chapter content, and do not copy word-for-word.

Answer: 

 Question 2

Question 2

CHAPTER 13 - THE SYSTEM = What EHR system was UCSF using and how long had they been using it?

Answer:

 Question 3

Question 3

CHAPTER 13 - THE SYSTEM = What was UCSF hospital's approach to "alerts" in the system? What was their reason for this?

Answer:

Question 4

Question 4

CHAPTER 14 - THE DOCTOR = What had Dr. Lucca been told to do with the alerts in the system? Why?

Answer:

Question 5

Question 5

CHAPTER 14 - THE DOCTOR = Explain the decisions that Dr. Lucca had to make when ordering the medication for Pablo.

Answer:

Question 6

Question 6

CHAPTER 15 - THE PHARMACIST = What did the pharmacist, Benjamin Chan, do when he received Dr. Lucca's order? Why?

Answer:

Question 7

Question 7

CHAPTER 15 - THE PHARMACIST = When Dr. Lucca went back into the system to re-order the medication, what was the error that she made?

Answer:

Question 8

Question 8

CHAPTER 15 - THE PHARMACIST = In the chapter, the author names this type of user error made in a system where the same action can result in two very different results. What do we call this type of error?

Fill in the blank with the correct term.

Question 9

Question 9

CHAPTER 15 - THE PHARMACIST = Did the system alert Dr. Lucca about the medication overdose issue? How did she respond?

Answer:

Question 10

Question 10

CHAPTER 16 - THE ALERTS = What is "alert fatigue"? Provide a description and an example from the book to illustrate the meaning of the term.

Answer:

Question 11

Question 11

CHAPTER 16 - THE ALERTS = The author summarizes some experts' suggestions for how to address alert fatigue or false alarms. What are three of these suggestions?

Answer:

Question 12

Question 12

CHAPTER 16 - THE ALERTS = When Dr. Lucca explained why she responded to the overdoes alert the way that she did, she blamed two things - alert fatigue and the design of the system. What did she specifically mention about the design of the system?

Answer:

Question 13

Question 13

CHAPTER 16 - THE ALERTS = The error then got through the pharmacist Benjamin Chan as well. Chan discussed a few reasons for this - What are three of these reasons?

Answer:

Question 14

Question 140.25 pts

CHAPTER 17 - THE ROBOT = Pablo's Septra pills were prepared by a pharmacy robot - What step is removed when a robot prepares the pills instead of having a pharmacy technician prepare the pills?

Answer:

Question 15

Question 15

CHAPTER 18 - THE NURSE = Nurse Brooke Levitt was a "floater" the night of the incident - What is a floater and what was Nurse Nevitt's opinion of being a floater?

Answer:

Question 16

Question 16

CHAPTER 18 - THE NURSE = Even though Nurse Levitt noticed that there were a lot of pills, how did she justify administering that many to the patient?

Answer:

Question 17

Question 17

CHAPTER 18 - THE NURSE = Why did Nurse Levitt not ask a colleague if the number of pills seemed appropriate? (she mentions a few reasons so be sure to read all the way through and summarize more than just one reason)

Answer:

Question 18

Question 18

CHAPTER 19 - THE PATIENT = "Patient-centered" care is a new movement in healthcare that provides patients and their caretakers with more infomation to empower them to be their own advocates and to question the clinical care team if they think something is not right.

In the spirit of patient-centered care, Nurse Levitt asked Pablo about the large dosage - What did Pablo say and why?

Answer:

Question 19

Question 19

Imagine you are the CEO of this hospital, Mark Laret (https://chancellor.ucsf.edu/leadership/chancellors-cabinet/mark-laret (Links to an external site.)).

Your team has provided you with a summary of the incident, which was provided in the chapters 12-19 that you just read.

You are asked by a quality assurance group to hold one of the entities "ultimately accountable" for this error, a common practice when a clinical error occurs - The entities include:

• The system, including the ordering process, alerts, and screen designs (chapters 13, 16)
• The doctor - Dr. Lucca (chapter 14)
• The pharmacist - Benjamin Chan (chapter 15)
• The pharmacy robot (chapter 17)
• The nurse - Nurse Levitt (chapter 18)
• The patient - Pablo Garcia (chapter 19)

Who do you pick as being "ultimately accountable" and why? Support your answer with at least 2 justifications that relate back to the book chapters.