DDHA 8601 Week 9 Downtime Plan Example

When the Record and the Cabinets Go Down: A Downtime and Risk Plan for Pharmacy and Inpatient Units, With Roles Named First and Recovery Written in the Most Detail

Student Name

Walden University

DDHA 8601: Technology and Innovation in Healthcare

Instructor Name

Month Day, Year

When the Record and the Cabinets Go Down: A Downtime and Risk Plan for Pharmacy and Inpatient Units, With Roles Named First and Recovery Written in the Most Detail

Purpose

This plan tells pharmacy and inpatient unit staff at Linden Ford, the composite hospital used throughout this course, what to do when the electronic record, the electronic medication administration record and the automated dispensing cabinets are unavailable, and how to return the work done on paper to the record afterward. It separates planned downtime, which is scheduled and announced, from unplanned downtime, which is not, because people behave differently in each. The units and incidents referred to are composite.

Roles, Before Actions

Five roles carry this plan. They are named by title so the plan works on any shift.

The administrator on call declares an unplanned downtime after the information technology service desk confirms that the record is unavailable to more than one unit for more than fifteen minutes. Planned downtimes are declared in advance by the chief information officer.

The house supervisor tells every inpatient unit, by phone and overhead page, that downtime procedures are in effect, and tells them again when the record is restored.

The pharmacy operations manager, or the pharmacist in charge after hours, directs pharmacy downtime procedures, including cabinet override access and paper order verification.

The charge nurse on each unit makes sure the unit's downtime box is opened, paper medication records are in use and every administration is written down at the time it happens.

The chief medical information officer, or the designee on call, decides when the system can be trusted again. Systems coming back online do not mean the data in them are complete, and this role, not the service desk, declares the all clear for clinical use.

Planned Downtime

Planned downtimes, usually for upgrades, are scheduled between 01:00 and 05:00 and announced to units at least 72 hours ahead. Two hours before the start, each unit prints its patients' medication administration records from the record system, covering the next six hours, and pharmacy loads the automated cabinets with expected doses. During the downtime, nurses document administrations on the printed records, and new orders are written on paper order forms and faxed or carried to pharmacy. Read-only access to the record is maintained on one marked workstation per unit, refreshed every fifteen minutes before the start. Sittig et al. (2014), surveying recommended practices for contingency planning, describe read-only backup access and printed medication records as core safeguards, and both are in place here.

Unplanned Downtime

In an unplanned downtime there is no time to print. When the house supervisor announces it, each unit retrieves its downtime box, which holds blank medication records, order forms and the most recent automated census and medication report, printed every four hours by a scheduled job. Nurses use the most recent report to rebuild each patient's current medications on paper and check it against the patient's wristband and the bedside. The automated cabinets continue to dispense in override mode if their network connection fails, limited to the medications on each cabinet's emergency list; pharmacy delivers other doses by hand against paper orders verified by a pharmacist. High-alert medications such as insulin and heparin require a second nurse's check on paper, as they do electronically. If the downtime passes four hours, the pharmacy operations manager decides whether to send a pharmacist to each unit.

Recovery: Getting Paper Work Back Into the Record

Recovery is the longest section because it is where errors are created. Wang et al. (2016), timing laboratory work at hospitals before, during and after computer outages, found that delays continued after the system returned, as staff worked through backlogs. Larsen et al. (2018), analyzing patient safety event reports involving record downtime, found reports describing medication problems, delays and lost information.

When the chief medical information officer declares the all clear, recovery proceeds in a fixed order. First, pharmacists enter every paper order written during the downtime into the record, marking each as a late entry with its original time. No nurse back-documents an administration until the order it relates to is in the record, so that every administration links to an order. Second, nurses enter administrations from the paper records, again as late entries with the actual time given. Third, the charge nurse checks each patient's paper record against the electronic record line by line, looking for three specific errors: doses given on paper but not entered, doses entered twice because two people documented the same administration, and doses due during the downtime that were missed. Fourth, the pharmacist in charge reviews the cabinet override report against the entered administrations and investigates any dose removed from a cabinet with no matching administration. Paper records are kept on the unit until this reconciliation is signed by the charge nurse, then sent to health information management to be scanned.

Recovery after a long downtime can take longer than the downtime itself. The plan therefore allows the house supervisor to bring in an additional nurse per unit for back-entry after any downtime over four hours, so that bedside care is not delayed by documentation.

Risks

Table 1

What Could Interrupt the System

Likelihood is expressed in words from the hospital's history and the information technology department's judgment; no probabilities are invented.

Drills

Each inpatient unit and the pharmacy will run one unannounced downtime drill a year, including a recovery exercise on a test patient. The drill will be judged by the recovery reconciliation, not by how smoothly staff switch to paper, because that is where the record is most likely to go wrong.

References

Larsen, E., Fong, A., Wernz, C., & Ratwani, R. M. (2018). Implications of electronic health record downtime: An analysis of patient safety event reports. Journal of the American Medical Informatics Association, 25(2), 187-191. https://doi.org/10.1093/jamia/ocx057

Sittig, D. F., Gonzalez, D., & Singh, H. (2014). Contingency planning for electronic health record-based care continuity: A survey of recommended practices. International Journal of Medical Informatics, 83(11), 797-804. https://doi.org/10.1016/j.ijmedinf.2014.07.007

Wang, Y., Coiera, E., Gallego, B., Concha, O. P., Ong, M.-S., Tsafnat, G., Roffe, D., Jones, G., & Magrabi, F. (2016). Measuring the effects of computer downtime on hospital pathology processes. Journal of Biomedical Informatics, 59, 308-315. https://doi.org/10.1016/j.jbi.2015.12.016