NURS 6401 Week 9 case analysis example

Built as Designed, Abandoned in Two Weeks: A Case Analysis of an Electronic Neurological Check Module and the Four Decisions That Made Its Workarounds Predictable

Student Name

College of Nursing, Walden University

NURS 6401: Informatics in Nursing and Healthcare

Instructor Name

Month Day, Year

Built as Designed, Abandoned in Two Weeks: A Case Analysis of an Electronic Neurological Check Module and the Four Decisions That Made Its Workarounds Predictable

Case Summary

This case is a composite, built from patterns reported in published implementation research rather than from any one hospital. A 280-bed community hospital replaced paper neurological check sheets on its two neuroscience units with an electronic module. The module presented a timed neuro check task based on the ordered frequency, recorded level of consciousness, pupils, motor strength and speech in structured fields, and sent an automatic page to the charge nurse if a check was more than fifteen minutes late or if the Glasgow Coma Scale total fell by two points or more. Nurses would document at the bedside on wall-mounted workstations installed in each room.

The module went live on schedule on a Monday and worked exactly as built. Within two weeks, three workarounds had appeared. Nurses were entering checks at the station after rounds, back-timing them to the scheduled time. Patients who were in imaging or at procedures at check time generated late-check pages, so nurses began documenting a check before the patient left the unit and entering the next one on return, with times adjusted. And on nights, some nurses kept a paper sheet taped inside the room door, as before, and transcribed it later. By the end of the first month, the charge nurses reported that they ignored most late-check pages. Nothing in the software had failed; the rollout had been designed around a day shift that did not exist at night.

Analysis: Four Decisions

Implementation research describes technical, social and organizational factors as interrelated, so that success depends on balancing implementation decisions rather than on the technology alone (Cresswell & Sheikh, 2013). The four decisions below each had an owner, and each made the workarounds more likely.

Decision 1: The Workflow Analysis Sampled Day Shift Only

Owner: the project's clinical workflow analyst, with the nurse manager's approval of the schedule. The analysis observed neuro checks on four weekday day shifts. On days, patients are awake, visitors are present, and most imaging and procedures happen with transport arranged in advance. On nights, many checks require waking a sleeping patient in a dark room, and off-unit travel happens unpredictably for urgent scans. The module's timing rules, room workstations and paging threshold all fitted the observed shift. A night observation would have shown that nurses often assess by flashlight without logging in to a bright screen, and that off-unit status needed a documentation option of its own.

Decision 2: Training Was Scheduled Where Night Staff Could Not Attend

Owner: the education department, which scheduled four-hour classroom sessions on weekday afternoons in the two weeks before go-live. Night staff could attend only by coming in on a sleep day or after a shift. Most completed a brief online module instead, which covered where to click but not the rules for off-unit patients or the paging threshold. Night staff therefore met the pages for the first time during live care, without an explanation of why they were firing.

Decision 3: Super-User Coverage Ended at the Go-Live Weekend

Owner: the project manager, who budgeted super-user hours for go-live day and the following weekend. After that, super-users returned to full assignments. The first time a patient went to imaging during a check on a Tuesday night, there was no one on the unit to say how to document it. Workarounds that go unaddressed in the first days tend to become the working method; studies of workarounds show that they arise from a mismatch between how a system expects work to happen and how it does, and that they persist when no one acts on them (Koppel et al., 2008).

Decision 4: Nursing Complaints Were Routed to a Help Desk Queue

Owner: the information technology service manager, who defined the escalation path. Problems were to be reported to the general help desk. The help desk treated off-unit paging and back-timed entries as user behavior rather than system issues, closed the tickets and did not forward them to the informatics nurse. Unintended consequences of clinical systems often surface first as small complaints from users, and the chance to correct them is lost when those complaints go where no one can interpret them clinically (Ash et al., 2004).

What the Four Have in Common

Each decision was reasonable within its owner's own frame. The analyst observed when observation was convenient, education scheduled when classrooms and trainers were available, the project manager spent the super-user budget where the risk seemed highest, and the service manager used the queue that handles every other ticket. None of them was asked to consider the night shift as a separate context, and no one on the project had the job of doing so. That is the role an informatics nurse on the project team would have held: not to make the four decisions, but to ask each owner the question the project's structure did not ask. The pattern also explains why the workarounds were predictable rather than surprising. Every workaround appeared on nights first, at the points where the four decisions left night nurses without a fitting option, training or support.

Recommendations to the Same Owners

To the workflow analyst: observe at least two night shifts and one weekend shift before any future module design, and add an off-unit status to this module that pauses the timer and requires a check on return. To the education department: offer training in short sessions at the start and end of night shifts, paid, and include the paging rules and off-unit procedure in every session. To the project manager: extend super-user coverage on every shift for at least two weeks after go-live, with a named super-user on nights. To the service manager: route any ticket from a nursing unit that mentions a clinical workflow to the informatics nurse within one business day. Finally, the charge nurses' report that they ignore most pages should be treated as the most important finding of the first month, because an alert that is ignored provides no protection.

References

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

Cresswell, K., & Sheikh, A. (2013). Organizational issues in the implementation and adoption of health information technology innovations: An interpretative review. International Journal of Medical Informatics, 82(5), e73-e86. https://doi.org/10.1016/j.ijmedinf.2012.10.007

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616