Proceedings of the 2008 Industrial Engineering Research Conference J. Fowler and S. Mason, eds.Applying SHERPA to Analyze Medication Administration in the Cardiac Telemetry Unit Abhinesh Bhuvanesh, Shengyong Wang, Mohammad Khasawneh, Sarah S. Lam, Krishnaswami Srihari Department of Systems Science and Industrial Engineering State University of New York at Binghamton Binghamton, NY 13902 Tejas Gandhi Management Engineering, Virtua Health Voorhees, NJ 08043 Abstract Medication administration is one of the most important and complex processes touching almost every patient that comes into the hospital. Consisting of five stages, namely prescribing, documenting, dispensing or preparation, administering and monitoring, the process is highly dependent on the effective and efficient interactions of health professionals from different disciplines. Previous research indicated the benefits of applying human factors to study medication errors and highlighted the need for healthcare providers to be more aware of human limitations and that system changes should be made to accommodate them. The Systematic Human Error Reduction and Prediction Approach (SHERPA), which is based on human errors taxonomy, analyzes tasks and identifies potential solutions to errors in a structured manner. The application of SHERPA for analyzing drug administration will be especially beneficial for hospital decision makers as they plan to integrate various technologies to improve this process. Therefore, this paper illustrates the application of SHERPA to the process of administering drugs to patients of the cardiac telemetry unit at Virtua Health, a multi-hospital healthcare system headquartered in Marlton, NJ, particularly as a means for preventing (or reducing) errors and comparing alternative administration technologies. Keywords Medication administration, SHERPA, human error, cardiac telemetry unit. 1. Introduction Medication errors are a global problem and are typically defined as deviations from a physician's order, with hospital medication error rates reaching as high as 1.9 per patient per day [9]. Even with this high incidence many go unreported because nurses fear the consequences of reporting an error [19]. Many major medical error studies highlight medication errors as a cause of adverse events suffered by patients [14, 16]. Ferner and Aronson [6] define a medication error as ‘‘a failure in a drug treatment process that leads to or has the potential to lead to harm to the patient.’’ Even though medication errors may or may not result in an adverse effect, they indicate a low level of safety in health assistance [18]. According to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), drug-related incidents may be classified into groups and include adverse reactions, adverse effects, and medication errors [18]. An Adverse Drug Reaction (ADR) is defined as every harmful and undesirable effect occurring after a drug is administered in doses usually used by man for prophylaxis, diagnosis, or treatment of a disease or with the aim of changing a biological function [18]. An Adverse Drug Event (ADE) includes medication errors and adverse drug reactions, which may be classified as avoidable or unavoidable [18]. Finally, a dispensing error is defined as the discrepancy between the written order in a medical prescription and its fulfillment. Dispensing errors, are typically made by the pharmacy staff, including pharmacists, while dispensing drugs to hospital units [2, 8], comprise the types of medication errors that are most harmful to patients. Medication administration is one of the most important and complex processes touching almost every patient that comes into the hospital. It consists of five stages, namely prescribing, documenting, dispensing or preparation, administering and monitoring. This makes the process is highly dependent on the successful and efficient interaction of health professionals from different disciplines [15]. There are many different causes of medication errors like 1677 wherein all the floor medications. then the nurse has to fill a medication order for the patient and give it to the unit secretary for further processing. which include the medication name. the focus of this study was on the acquisition of meds by nurses to the drug administration to the patients in the cardiactelemetry unit. the methods required to improve specific aspects of the task can be identified. Researchers also cite other causes such as the lack of proficiency in the calculation of drug doses [23] and rates of administration and lack of information about the patient [16]. the nurse prepares and administers the medications and updates both the nursing and patient records. 2. constant interruptions. radiology/doctors instructions. In this study. route. As soon as the nurse starts his/her shift. 20]. A Human Factors Approach to Medication Administration Errors The focus of this study was to explore the procedure for administering drugs to patients and examine the task steps. shift patterns [5]. to ascertain the correctness of the medications. The MARs have to be the most recent and should have been updated by the night shift nurse at 10 PM daily. According to Wolf [24]. Even though nurses seek to give medications correctly. Khasawneh. which aids in evaluating what type of training is needed to bring the personnel to superior performance levels. structured and un-structured interviews. constant interruptions. which represents a list of patients (usually 4 to 5) that he/she has to take care of. it is a complex activity that carries a high risk of error due to the involvement of different healthcare professionals. Human error analysis facilitates the understanding of how human interaction with drug administration tasks might lead to incidents. Each dose administered is recorded on the medication chart. and the relationships among these factors. Physicians use the patient’s chart to indicate to the nurse which medications the patient is to receive. Therefore. are stored in the automated point-of-use unit dose drug distribution Pyxis machines in medication rooms. which are located at the nurse station. and are checked at the beginning of the shift on a daily basis. shadowing. Wang. Hierarchical Task Analysis (HTA) helps in isolating the critical characteristics of the tasks by delineating them in an orderly way at different levels of details. which is automatically generated whenever a pharmacists profiles a patient order.Bhuvanesh. The nurse checks patient records for any new orders/appointments. CMARs are located on the medication-carts in the hallways of each unit. he/she receives a patient assignment for the shift. HTA has been extensively used to study human error. and the medication administration round when it is to be administered. At each level. The nurse is required to crosscheck the MARs in the patient records with the Computerized Medication Administration Records (CMARs). The nurse then checks the patient specific compartment in the Pyxis system for medications not present in the patient specific compartments on the med-carts. the equipment used. both common and patient specific. dose. as she or he is the last person in the drug administration chain. which usually shows 3-4 days of documentation allowing for viewing of the patient’s most recent medication history. procedural changes etc. appropriate verbal protocol analysis. depending on the type of unit. which makes it inherent that errors may occur at any stage of the process [10]. jobdesign. human-computer interaction. conflicting demands and high workloads. Lam. training. and analysis of company wide procedures/documentation and training manuals [3. A consistent medication administration process is necessary to support an integrated approach to delivering and managing pharmaceutical care in an organized delivery system. Srihari and Gandhi workload. communication failures [7]. Patient charts are kept at the nurse station and used to record medication administration. Medical staff also need to know which medication is needed and when. and allocation of functions and assessment [21]. direct observation and shadowing were carried out of nurses in the cardiac-telemetry unit at Virtua Health’s Voorhees campus for developing the HTA (see Figure 1). long working hours [11] and these often combine to cause the incident. Successful medication administration is dependent on an effective patient information and patient monitoring system. The Medication Administration Task At Virtua Health. the hospitals use a ward pharmacy system. The systematic analysis of the medication administration process at task level will assist in assessing interventions to reduce errors through various design solutions like technology. the responsibility for the error is often placed on the nurse. followed by a check of the Medication Administration Records (MARs). The data used in HTA can be obtained through a variety of modalities. their efforts are often confounded by hard-to-read prescriptions. Once all the medications are available. Giving medications to patients is a fundamental nursing role. 3. human-machine interface design. etc. this information cannot be accurately ascertained in the absence of the medication chart. However. 1678 . If these are not available. including observation. Nurses make a medication administration round four to six times on a daily basis. Some medications that have a limited therapeutic range and various indicators (such as blood pressure or anticoagulant levels) have to be checked before being administered in the appropriate quantity. which can be used to analyze tasks and identify potential solutions to the errors in a structured manner. based on the patient’s condition. 13] compared SHERPA with five other human error identification techniques on the criteria of comprehensiveness. followed by immediate updating of the patient’s medication chart. which. such as patient admit. Figure 1. Wang. As soon as a patient is admitted to the unit. Khasawneh. Kirwan [12. in the original form. SHERPA Analysis The Systematic Human Error Reduction and Prediction Approach (SHERPA) was developed by Embery [4] for use in the process industries (conventional and nuclear power generation. Hierarchical Task Analysis for Nurse Tasks 4. RNs have to attach a cardiac monitor to the patient. medication. This human error identification technique allows the analyst to define the information that is useful for error reduction strategies. and the patient safety expert. patient discharge. Medication is a task that nurses do repetitively for every patient (typically 9 AM and 4 PM meds). The HTA was reviewed by nurse managers. patient records. The goal of patient treatment consists of several daily level 1 nursing tasks. Plan 0 indicates the activities or sub-goals that should be carried out to achieve the goal. The top-level goal of the system is to administer medications to the patient. Ongoing development of the technique has removed this reference to the underlying psychological mechanism. Once the nurse has acquired the medications. and every task associated with documentation is highlighted in light blue. and shift change. 1679 . followed by a check of the patient’s medication administration record. which makes it an inherent initial step in the medication administration process. The task begins. consistency. which makes it a vital part of patient treatment. then he/she prepares the correct dose and administers the drug to the patient. The HTA shows all the activities that an RN is required to do in the cardiac telemetry unit. patient rounds. petrochemical processing and oil and gas extraction). These activities are further broken down into operations at the lower levels. Srihari and Gandhi The high frequency tasks performed by the Registered Nurses (RNs) across these units have been highlighted in green. and then the nurse goes to the med-cart/Pyxis to obtain the scheduled medications. A critical task that RNs have to do in this unit is to frequently monitor the telemetry displays for patient condition. The steps necessary to do this are listed as tasks 1–6 on the next level of the hierarchy. accuracy. The involvement of cardiac monitors adds tasks that are unique to this unit. Lam. as the nurse first checks the patient records for any new notes. theoretical validity. specifies the psychological mechanism underlying the error. The technique is based on the taxonomy of human error.Bhuvanesh. The order in which these activities are carried out is determined by the plan defined in the diagram. the director of quality management. The types of error that may occur fall into one of the five behavior categories: action. with the consideration of the most likely error modes associated with that operation. These reliability and validity statistics are generally encouraging. For example. likely recovery 4: Medium adverse effect.’s work and application of SHERPA for the medication administration process in the cardiactelemetry unit at Virtua Health. The fourth column (i. respectively for the application of SHERPA by 25 novice users to the prediction of errors on a confectionery vending machine. whereas Stanton and Stevenage [22] reported concurrent validity and reliability statistics of 0. resource usage and auditability/acceptability to see if the incidents predicted by those techniques matched those that had actually occurred and found that SHERPA was the most highly rated by expert users. unlikely recovery 3: Medium adverse effect.74 and 0. which denotes that a check has been missed. only the most credible errors for the task step are taken into account.65. Srihari and Gandhi usefulness. “Description”). [15]. It is possible that prior to medication administration. SHERPA uses the bottom-level actions of the HTA as its inputs. Each error type in the taxonomy is coded and associated with an error mode. a description of the potential consequence of the activity is entered. Lane et al.8 and reliability as 0.9.e. The error mode C1 is entered in the second column. It 1680 . checking. and hence. The operations are evaluated for potential error using the human error taxonomy shown in Table 1.1). In the third column (i.3 in the HTA (i. the RN may fail to check telemetry monitor for the patients condition. task step 2. not complete the search.Bhuvanesh. these are not strictly errors.. Khasawneh.. these actions would prevent the goal of accurate and complete patient record. Looking at the associated checking error modes in Table 1. “Cardiac Monitor Records’’. or he/she may be called away to attend to another patient. unlikely recovery 5: Significant adverse effect.e. At this stage of the analysis. Moreover. [15] demonstrated the application of SHERPA for the medication administration process for the UK-based hospital systems. and selection.e. The study presented in this paper is an extension of Lane et al. The error table for the rest of the tasks can be reviewed in the study conducted by Lane et al. likely recovery 6: Significant adverse effect. In nursing terms. it is possible to make a prediction of what the consequence of that error might be. “Consequence”). Baber and Stanton [1] reported the concurrent validity as 0. Lam. which represent the operations or task steps carried out to achieve the higher-level goal. However. an outline of the error is described as: ‘‘fail to check telemetry display’’. 3. Wang.. likely recovery 2: Small adverse effect. which also affects medication administration and patient treatment. unlikely recovery Risk Priority Number = Σ p x q The results of the SHERPA analysis specific to cardiac monitors are recorded in tabular form (see sample in Table 2). communication.. with regards to SHERPA. with the fifth column indicating whether or not the error can be recovered. The task steps from the HTA are examined in turn and are classified into one of the error types. The first column indicates the number of the task step (i. retrieval. Table 1: SHERPA Error Modes [15] p = frequency of occurrence 1: Low 2: Medium 3: High q = severity of occurrence 1: Small adverse effect.e. as shown in Figure 1) is classified as a “checking” activity. or high (occurs frequently).” International Topical Meeting on Advances in Human Factors in Nuclear Power Systems. any design solution needs to be regulated by appropriate management and organizational controls. colleagues and various departments all impinge on the process of drug administration. If it is not possible to recover the error then this column is left blank. process redesign and system changes. R.” Applied Ergonomics. 1999. medium (has occurred once or twice).” Washington..). validation of the errors predicted in the model needs to be compared with data gathered by observation of actual medication delivery in the hospital for different ward settings to analyze both opportunity for error and the types of error that actually occur. M. TE. Diaper. and Stanton.. West Sussex.. Cohen. References 1. Whilst this paper focuses on the nursing activities on the cardiac-telemetry unit. Ferner.. Prevention and Risk Management. 27. 1996. “Human Error Identification Techniques Applied to Public Technology: Predictions Compared with Observed Use. product design or technological system) that could be taken to reduce errors. Task Analysis for Human-Computer Interaction. Communication with patients and their relatives. medication administration errors occur due to a number of varying and often interacting factors that may originate from organizational practices. 1681 . 5. 1998. UK. Furthermore. Knoxville. This would facilitate the understanding of critical tasks which may lead to medication errors. D.E. 2. The analysis predicts what steps can be taken to achieve resolution and highlights those aspects of the drug administration process where design solutions would have the greatest impact. “Medication Errors: Causes. Many of the tasks presented in the HTA could be subdivided into further levels of component tasks and operations. in order to be effectively implemented. 1986. Digitization of patient records and active use of computer technology by the hospital staff for documentation and updating patient treatment information will enable real time access of patient information by relevant parties. The final column shows the measures (e. American Pharmaceutical Association Foundation.A..g. (7003). Lam.E. It is important to note that.. N. 1995. the nurse will be able to go back and correct the original error or omission. C. [15].. thereby revealing a highly detailed description of the drug administration task. and identify strategies to mitigate them using technology.C. Srihari and Gandhi may be that by completing further task steps.Bhuvanesh. the working environment.R. “Misleading Drug Packaging. ensure that the RN checks the necessary conditions (like checking heart rate. or personal and professional practices. Khasawneh. The probability of the error occurring is denoted in the table by P. 311. which is categorized as low (hardly ever occurs).. According to Lane et al.. 119–131.” BMJ (Clinical Research Ed. D. similar extensions could be carried out at different hospital units and can be adapted to different ward settings for a range of other healthcare procedures. The task analysis could be extended to the medication delivery systems from pharmacy and predict errors that might occur due to unavailability and delays in acquiring medications in the unit. 4. Baber. Ellis Horwood Ltd. D. There are various technological interventions that hospitals are looking to reduce such errors. 3. Bar-coding and RFID are examples of technologies that can alleviate issues with patient identification during medication administration and by using various alerting measures. Discussion and Conclusions The main purpose for carrying out this analysis was to demonstrate the types of error that occur during medication administration in the cardiac telemetry unit and the location in the process where these errors occur. The strength of the SHERPA technique is that it can be used to analyze tasks or processes at many different levels. Table 2: Example of SHERPA Application 5. “SHERPA: A Systematic Human Error Reduction and Prediction Approach. 514. The error mode taxonomy prompts the analyst to consider potentially unforeseen errors and the error reduction strategies are readily identified. Wang. etc. Embery.) prior to medication administration. 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