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Resilience, Mindfulness and Medication Safety with Electronic Systems

Periodic Reporting for period 2 - MindSElS (Resilience, Mindfulness and Medication Safety with Electronic Systems)

Reporting period: 2020-01-01 to 2020-12-31

Medication safety is one of the most serious concerns for patient safety across all healthcare sectors, and one of the most challenging to address. The complexity of healthcare delivery calls for an approach to medication safety that builds on learning from ‘everyday resilience’, and one way to achieve organisational resilience is through mindful organising. In particular, five dimensions have been identified in high-reliability organisations contributing to resilience, reliability and safety, in aggregate known as ‘collective mindfulness’: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise [1].
Electronic medication management systems are being introduced in hospitals worldwide with the aim of improving medication safety. However, there is evidence of negative consequences and technology design and implementation may undermine the potential for resilience and therefore affect an organisation’s capacity for collective mindfulness. Research on the consequences of introducing electronic medication management systems for collective mindfulness is limited and fragmented.

Resilience, Mindfulness and Medication Safety with Electronic Systems (MindSElS) is a Marie Skłodowska-Curie Global Individual Fellowship awarded to Dr Valentina Lichtner (‘the fellow’). It is a collaboration with UCL School of Pharmacy (University College London, UK) and the Centre for Health Systems and Safety Research (CHSSR) at the Australian Institute of Health Innovation (AIHI, Macquarie University, Sydney, Australia).

The MindSElS project aims to improve medication safety in hospital inpatients by:
- developing theory and method for evaluation of individual and collective mindfulness associated with electronic medication management systems;
- investigating whether and how this technology can support organisational resilience in the use of medications;
- providing guidance for technology implementation aimed at achieving and sustaining resilience.

To address these aims, we propose [2] a framework of six research questions (Q) underpinned by sociotechnical assumptions and human factors understanding of technology in the workplace. For this project, we focused on Q1-Q3 applied to medication:
Q1. How does mindfulness manifest in medication work practices?
Q2. Does the current sociotechnical system support mindfulness? What role do existing tools have on staff ‘rescuing’ potential patient safety near misses?
Q3. How do practices change with the implementation of heath IT? What role has the new technology on maintaining mindfulness?

1. Sutcliffe and Weick, Mindful Organising and Resilient Healthcare, in: Resilient Health Care, 2013, Ashgate: London.145-156.
2. Lichtner, Franklin, and Westbrook. Stud Health Technol Inform, 2019. 265:31-36.
The fellow completed the first two years of the MindSElS research (2018-2019) at the Australian Institute of Health Innovation (AIHI, Macquarie University) in Sydney, Australia, and the third year in Europe in 2020 working remotely with UCL School of Pharmacy, in compliance with COVID-19 pandemic restrictions. In Australia, the fellow joined the local research team on an ongoing research project on the impact of electronic medication management systems on medication safety in a children hospital in Sydney [1]. She contributed to this project and developed her research on the effects of electronic medication management systems on individual and collective mindfulness among hospital clinicians, with two studies, one in paediatric oncology and one in a paediatric intensive care unit.

Overall, the project identified opportunities and challenges for collective mindfulness in hospitals in the use of technology for medication safety. A particular area of concern appeared to be the embedded automation. We found [2] that electronic medication systems, with embedded automated decision support and workflow management rules, may contribute to medication safety by facilitating strategies typical of the ‘ultra-safe’ model of safety (typically, standardization) and by operating ‘safety by design’ (e.g. embedded rules and constraints). However, we also found [3] that systems’ automated behaviours conceal issues with software, and contribute to clinicians’ frustrations and ‘incorrect use’ of the system. Thus, we concluded [2], for the system to be operated safely, clinicians must show a collective mindfulness with the technology - its limitations, and the embedded automation -, in addition to mindfulness with the patient situation and the context of work. We also found that different electronic medication systems pose different challenges to clinicians’ collective mindfulness. For example, in using electronic prescribing systems the challenge is to maintain a ‘sensitivity to operations’ - an awareness of the interdependencies in workflows, in a patient treatment, and within the wider hospital organization. Instead, in using an automated dispensing cabinet for example, the challenges is for the nurses not to rely on automation, as this risks a ‘drift into failure’ (as we argue in [4]). The challenge is for nurses to maintain a preoccupation with the potential for medication errors, despite the technology usually dispensing the medication correctly.

Studies results and theoretical and methodological reflections have been published in 5 journal papers, a book chapter and 3 chapters in conference proceedings. They have also been presented at local and international conferences/events. A conference paper has been accepted, and 3 more journal papers have been submitted (under review), when the fellowship ended in December 2020. The research is continuing beyond the end of the fellowship, with collaborations in the UK, the EU and Australia. AIHI granted the fellow an honorary position for her to continue collaborations with the Institute in the future.

1. Westbrook, et al., BMJ Open, 2016. 6(10).
2. Lichtner et al.. BMC Medical Informatics and Decision Making, 2020. 20(1):193.
3. Lichtner, et al. Eur J Cancer Care, 2019. 28(6):e13152.
4. Lichtner. Researching the drift into medication errors with automated dispensing cabinets: reflections from a study of a paediatric ICU (Accepted for publication) NI2020 International Congress on Nursing Informatics (now 2021)
This fellowship project delivered knowledge and methods for the benefit of patients and clinicians, healthcare organisations and society overall.
The results of our research were shared with the technology implementation teams at the hospital in Sydney, informing changes to the design of the system and the training of clinicians in its use, also for subsequent implementations. The evaluation project demonstrated a substantial reduction of medication errors in the children hospital – and associated potential harm - after the implementation (forthcoming). Theoretical and practical insight from this fellowship, have been published in international journals and conferences, contributing to the knowledge base on the subject of technology and patient safety. The fellowship enhanced the potential and future career prospects of the fellow. She has now a strong publication record and an established international network and collaborations, both in Europe and Australia.
Researching technology in healthcare complex workflows
Sensitivity to operations with electronic prescribing and administration systems in hospitals