Question

Ilmology is present esented in memory. If the degree of domeny s using technical Work System BOX4-5 Case Study in Human Factors in a complex Sociotechnical are un al needs in intensive care un fections and to reduce the ch technology (health IT) use cision support. Glucommande es to change intravenous or luce the chance h ) used in An important concern for managing patients with complex medical ne is blood glucose control in order to avoid the development of infections of longer lengths of stay in ICU. Glucommander, a health information techo many ICUs. helps physicians make insulin dosing orders through decision is interactive: It tracks the patient's glucose levels and guides nurses to chan subcutaneous insulin doses consistent with the physicians'orders. In an ideal ICU environment, the only persons to interact with the Glucon registered nurses who have been trained on the software and insulin protocol with a limited number of computers, other healthcare providers such as OCCUP physical therapists, physicians, respiratory therapists, dieticians, unit secretaries a use computers where Glucommander software is running. With so many provid computer, the Glucommander software occasionally gets accidentally closed with knowledge. This leads to a potential medication error in the insulin infusion rate, ani time between blood glucose checks, and a potential loss of the insulin rate infusion hi the Glucommander are the din protocol. However, in ICUS as occupational therapists, secretaries, and nurse techs/aids many providers using the same losed without the nurse's fusion rate, an incorrect lapse of v with multiple interruptions from ones, overhead pages, patients' needs The physical environment in the ICU is often hectic and noisy with multiple interrun other staff, alarms, other medical devices, portable pagers, telephones, overhead pages na and family members. The computers are located outside of each patient's room in a cubby area shared with all providers involved in the patient's care. No defense against the Glucommander's hain closed accidentally is present except one confirmation box. A registered nurse, caring for two to three critical patients at various locations in the ICU, may not know if the Glucommander has been turned off. Long lapses can occur before the nurse knows the software is off. Check Your Understanding 1. What conditions create the potential for medication errors in this situation? 2. What can a registered nurse do to protect patients who are on the Glucommander proto 3. What responsibility does a registered nurse have if the software is stopped by accio 4. What are possible solutions to prevent accidental closing of the software

Answer 1

1)The potential for medication error

Glucommander software stops during other operation without nurse knowledge.

It may alter infusion rates

2) Nurse should keep a check on the software Everytime any other function is perfomed on the computer.

She should assist with glucommander while performing any task on computer.

3) The responsibility of nurse is immediately glucommander software IT. About the situation and check for complications in the patient.

Evaluation blood glucose levels in patient associated and administration of insulin as per requirement.

Call the concerned doctor if necessary and ask for their opinion.

4) there should be a separate computer for glucommander and should not be shared with all provider.

Glucommander IT should always be present on monitor.

In case of shortage of IT he should probably check about working of software after every task performed at the computer.

There should be clear instructions about how to avoid closing of software and how to check for it. And should be circulated to every oerspe concerned with ICU.