The human factor in medicines management in nursing homes

The entire webinar recording can be found at the bottom of this article.

Why is it so difficult to administer the correct medication?

Kristian Ringsby Odberg begins by telling a personal story about a time when things went wrong. He was a newly qualified nurse in charge of a twin room on a surgical ward. On this particular day, two women were hospitalised. They had the same name, were born in the same year, had undergone the same procedure and received the same amount of opioids. When Odberg was due to insert new syringes, he arrived well in advance and had everything double-checked by a colleague.

'There was a lot of room for things to go wrong. Things went wrong despite the fact that we seemed to do everything right,’ says Odberg.

As simple as giving a patient a pill?

It's not like A leads to B leads to C. Healthcare is an enormous, man-made system with social and technological aspects. Each layer of patients, healthcare workers, physical spaces, processes, devices and society itself adds to the complexity of the system.

Odberg investigated medication management in two different nursing homes. Some of the challenges he observed were:

• The computer systems don't talk to each other.
• Nurses are often interrupted and rarely get to work in peace and quiet.
• Changes to multi-doses mean that nurses have to cut open the bags to get it right.
• The medication room is far away.
• Information is dispersed in different modules or programmes.
• Excessive faith in technology means we don't think or check.
• When technology is bumpy, we lose faith in it and start double documenting.

Research has documented anywhere from 30 to 150 steps in something as seemingly simple as administering a tablet to a patient. When the system is so complex and intricate, it's no wonder things can go wrong.

Better systems on the way?

Adverse events occur in 3-16% of all hospital stays. Can technology take some of the blame?

Technology never acts in isolation. It is part of a man-made system. In theory, a technological system can work perfectly. Then it encounters reality where it still doesn't fit in well. Healthcare professionals have to adapt. Sometimes the shortcuts work, other times they lead to challenges for patient safety.

If we want to improve quality and patient safety, we must create better systems!

‘We must always take the context into account. We need to look at the interaction between people, the environment and technology,’ Odberg emphasises.

Recording

You can download the podcast to your mobile on Apple Podcasts, Spotify or Podbean. Search for ‘Norwegian Centre for E-health Research’.