Example 11: Conflicts Between Technology and the Physical Environment

Issues Encountered

As a cost-saving alternative to installing computers in each patient room, a large academic hospital chose to invest in computers on wheels (COWs). The COWs were designed to roll anywhere they were needed and were intended to be especially useful at a patient's bedside. However, problems began to emerge after the COWs were put to use in the hospital. In rooms with two beds the COWs could easily be rolled to the bed nearest the door, but did not fit past the first bed to reach the second bed without having to move furniture. The nurses had several options for working around the problem. They could ask questions of patients from across the room, walking back and forth from the farthest bed back to the computer to enter information as they obtain it (e.g., blood pressure readings, pain levels), or they could speak to the patient privately and try to remember each of the answers so that they could enter the information on the computer at one time. Neither option was satisfactory. In addition to the challenges associated with getting the COWs into the patient rooms, the COW's batteries often failed without warning. This unfortunate feature led to the practice of the nurses plugging in the COWs whenever they were in use. This solution obviously negated one of the COWs most attractive features — their mobility.

Finding a Solution

Hospital staff brainstormed a couple of solutions to the problem. The first was to purchase laptops mounted on smaller carts, but these broke down constantly. To add to the problems, the laptops were unreliable and now form a small, lifeless herd in a corner of the hall and are often used as shelves for other items. The second solution was to modify the design of the COWs to make them slightly slimmer by removing the drawers under the computer, which hold the nurses' supplies and a sharps disposal bin (for disposal of used hypodermic needles and such). However, nurses said they need these supplies at hand to do their work. They felt that this solution was imposed without consultation of their needs as the users of the COWs.

This hospital struggled to find a satisfactory solution for the problem and encountered additional problems due to the approach used to try to address the original issue: The nurses felt that the proposed solution of the no-drawer cart was being imposed without consultation and without awareness of their needs. It probably would not have been difficult to solicit ideas from the nurses via e-mail, or just walking around with them. Hospital leadership could also have easily consulted with other hospitals of similar room design to consider their solutions. The IT department's response to the always-broken laptops appeared to be resignation. But efforts to solve the problem are ongoing.

In response to the problem with the battery failure on the COWs, the member of the hospital staff felt that the hospital could seek information about problems like these from users and might seek solutions from other hospitals and from vendors.

Lessons Learned

  • The physical layout of the hospital (i.e., patient room size and configuration) should be considered when purchasing any hardware for clinical use.
  • Leadership should actively solicit ideas from end users and seek to understand how users' needs lead to workarounds.
  • Failure to incorporate the ideas of end users leaves them feeling frustrated.
  • Seek input from other organizations on how they have solved similar problems rather than approaching your problem by trial and error.
  • To avoid making the same mistake twice, understand why previous "solutions" failed.

Source: Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008 Jul-Aug; 15(4): 408-23.

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