In one hospital, nurses' patient assignments were
communicated by listing the room numbers next to each nurse's name
in a computerized tool. At the beginning of a new shift, the
oncoming nurses listen to the taped report for each patient in
their assigned rooms.
At the start of one particular evening shift, a
nurse was assigned five rooms to cover per the paper assignment
list. However, the taped report for one of the bed locations was
empty. She concluded that the room had been vacated and was now
available for a new admission or transfer.
The nurse made rounds on each of
the patients for whom she had a report at the beginning of the
shift, completing the assessments, medications, and treatments for
each one. Mid-shift, the charge nurse inquired if there were any
status changes or other pertinent information regarding any of the
assigned patients. The nurse stated that there were none. Near the
end of the shift, the nurse recorded a report on her four patients.
At the end of the shift, the charge nurse asked why there wasn't a
taped report on the fifth assigned patient.
This came as a surprise, as the nurse had never
seen the fifth patient. She quickly visited the patient and
completed necessary assessments and care. Fortunately, the patient
was stable, was scheduled to be discharged in the morning, and had
not been scheduled to receive any medications or tests during that
shift. He was not harmed.
The concern for this neglected patient and the
potential for similar events in the future led to a root cause
analysis. The underlying cause was determined to be the lack of
confirmation of patient assignments by the accepting nurse. There
were multiple contributing causes. On this unit and throughout the
hospital, there were varying procedures for creating, checking, and
distributing nursing assignment lists by different charge nurses
and different, or sometimes no, methods for acknowledging
As a result, a rapid cycle
improvement was conducted, and its recommendations were implemented
on all inpatient units. First, nurses were to do an independent
double-check of the nursing assignment list made by the charge
nurse using consistent symbols with standardized meanings. Second,
at shift change, oncoming nurses would be required to enter their
own names next to the names of patients they had been assigned in
the electronic patient tracking tool. This would acknowledge
communication of assigned patients. Lastly, the charge nurse would
compare the assignment list to the completed electronic sign-in
tool and address any discrepancies.
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|Hardware and software computing
Focuses on the hardware
and software required to run the applications along with all the
machines, devices, and software required to keep the computing
Includes everything on
the data-information-knowledge continuum stored in the system
(i.e., structured and unstructured textual or numeric data and
entities to interact with the system and includes aspects of the
system that users can see, touch, or hear.
Humans (e.g., software
developers, system configuration and training personnel,
clinicians, and patients) involved in the design, development,
implementation, and use of HIT.
|Workflow and communication
people need to work with others in the health care system to
accomplish patient care.
|Internal organizational policies, procedures, and
and committees write and implement IT policies and procedures
responsible for overseeing HIT system procurement, implementation,
use, monitoring, and evaluation.
|External rules, regulations, and pressures
Accounts for the
external forces that facilitate or place constraints on the design,
development, implementation, use, and evaluation of HIT in the
|System measurement and monitoring
and monitoring programs address four key issues related to HIT
features and functions: availability, use, effectiveness, and
HIT, health information technology.