Description of Event or Problem · 1
RN B LOGGED ONTO HED (MCKESSON'S HORIZON EXPERT DOCUMENTATION) ON MOBILE COMPUTER AND CHARTED HER ASSESSMENTS ON HER 5 ASSIGNED PATIENTS. AT SOME POINT DURING HER HED CHARTING SHE NOTICED THAT A DIFFERENT NURSE'S NAME WAS NOW NOTED ON BOTTOM OF SCREEN. ALL OF HER CHARTING WAS CREDITED TO ANOTHER OFF-DUTY RN. THE HELPDESK CONTACTED HED RESOURCE RN AND THE CHARTING WAS ALL REMOVED. B THEN LOGGED IN AGAIN AND RE-DID ALL OF HER CHARTING. IT WAS FELT THAT THE OTHER NURSE HAD NOT LOGGED OFF PROPERLY, CREATING THE 'MIX-UP". AT THE END OF HER SHIFT, B CAREFULLY LOGGED OFF, BELIEVING THAT THE PRIOR NURSE LOG OFF WAS SOMEHOW NOT DONE PROPERLY. RN C THEN ASSUMED CARE OF THOSE SAME PATIENTS AND SHE LOGGED ONTO THAT SAME COMPUTER. SHE BEGAN HER CHARTING ON HED AND ALSO NOTED SOME TIME INTO HER CHARTING THAT THE NAME AT THE BOTTOM OF THE SCREEN WAS NO LONGER HERS, BUT B. SHE CONTACTED B WHO WAS STILL IN-HOUSE AND NOTIFIED THE HELP DESK OF THE RECURRENT PROBLEM. A TECH WAS SENT TO CHECK OUT THE COMPUTER ON WHEELS. HE SEEMED TO KNOW IMMEDIATELY WHAT THE PROBLEM WAS. THE UNIT WAS PULLED FROM SERVICE UNTIL HE COULD "RE-PROGRAM IT'.LESS THAN A MONTH AGO, A DIFFERENT RN ON A DIFFERENT UNIT EXPERIENCED THE SAME THING. SHE LOGGED OFF OF HER COMPUTER WHEN FINISHED CHARTING. NURSE TAKING OVER FOR HER CHARTED ON HED AFTER LOGGING IN AND NEVER NOTICED THAT THE FIRST NURSE'S NAME APPEARED THROUGHOUT THE PATIENT'S RECORD ON THE NEXT SHIFT. THE DAY SHIFT NURSE FOUND THE ERROR THE NEXT MORNING WHEN SHE RESUMED CARE OF THAT PATIENT. IT APPEARED ON THE HED THAT THE FIRST NURSE HAD PROVIDED ALL CARE AND MEDICATIONS FOR OVER 24 HOURS. THE HELP DESK WAS NOTIFIED AT THAT TIME AND THE CONCLUSION WAS AGAIN "LOG-ON ERROR BY NURSE". THIS SAME PROBLEM WAS NOTED SEVERAL MONTHS AGO WHILE INVESTIGATING A "MISSED OPPORTUNITY" TO GIVE AN ANTIBIOTIC WITHIN 4 HOURS OF ARRIVAL. ALTHOUGH THE PATIENT DID NOT ARRIVE AT THE HOSPITAL UNTIL NOON, THE NURSE'S HED CHARTING INDICATED THAT THE ADMISSION ASSESSMENT WAS DONE AT 0700 WHICH IS WHEN THAT PARTICULAR NURSE HAD FIRST SIGNED ON FOR THAT SHIFT ON THAT COMPUTER. SINCE DISCOVERY OF THE ISSUES, IT NURSES HAVE BEEN ABLE TO REPRODUCE THE SCENARIO, WHICH CAN HAPPEN IF A CERTAIN SEQUENCE OF EVENTS TALKS PLACE. SHORT VERSION IS, THE SYSTEM IS WORKING AS DESIGNED.LET ME EXPLAIN THAT LAST STATEMENT:IT IS POSSIBLE FOR ONE TO LOG INTO THE SYSTEM AND THEN LOG OUT OF PART OF THE SYSTEM WITHOUT COMPLETELY LOGGING OUT OF ALL OPEN APPLICATIONS.SEQUENCE OF EVENTS TO DUPLICATE WHAT HAPPENED:NURSE LOGS INTO CARE ORGANIZER.NURSE SELECTS PATIENT.NURSE OPENS FLOW SHEET.FLOW SHEET OPENS IN A NEW WINDOW.AT THIS TIME BOTH CARE ORGANIZER AND THE FLOW SHEET HAVE THE SAME PERSON LOGGED IN.BECAUSE THERE ARE 2 WINDOWS YOU NEED TO SWITCH BETWEEN THEM TO SELECT OTHER PATIENTS, DO OTHER TASKS, ETC IN CARE ORGANIZER AND THEN SWITCH BACK TO THE FLOW SHEET. SOMETIMES THE FLOW SHEET (OR BOTH WINDOWS) IS MINIMIZED.NEXT, IT'S TIME TO LOG OUT.NURSE SELECTS CARE ORGANIZER.NURSE LOGS OUT.CARE ORGANIZER CLOSES BUT THE FLOW SHEET IS STILL OPEN AND LOGGED IN AS YOU. CARE ORGANIZER DOES NOT AUTOMATICALLY CLOSE THE OPEN FLOW SHEET WINDOW.THE OPEN FLOW SHEET MAY NOT BE NOTICED BECAUSE IT MAY BE MINIMIZED.NEXT NURSE COMES ALONG AND OPENS UP CARE ORGANIZER.NURSE LOGS INTO CARE ORGANIZER.NURSE SELECTS PATIENT.NURSE OPENS THE FLOW SHEET.MINIMIZED FLOW SHEET IS CHANGED TO THE PATIENT SELECTED BY THE NURSE.NURSE MAXIMIZES THE FLOW SHEET AND BEGINS TO CHART. HOWEVER, THE PRIOR NURSE IS STILL LOGGED INTO THE FLOW SHEET BECAUSE THE APPLICATION WAS NOT CLOSED BY THE FIRST NURSE.WE WERE ABLE TO REPRODUCE THE ABOVE SCENARIO WITH EASE.OK, SO WHAT DO WE DO ABOUT THIS ISSUE?FIRST, REMINDER TO STAFF TO LOG OUT OF ALL OPEN APPLICATIONS WHEN THEY LEAVE THEIR DEVICE.SECOND, WE ARE DEPLOYING A REPLACEMENT FOR THE CARE ORGANIZER WITH WHAT IS KNOW AS COMMON APPLICATION FRAMEWORK OR CAF. CAF REPLACES THE CURRENT CARE ORGANIZER WITH A CONSISTENT WAY OF DISPLAYING PATIENT DATA ACROSS MULTIPLE APPLICATIONS. MORE IMPORTANTLY, THE FLOW SHEET NO LONGER OPENS IN A SEPARATE WINDOW. IT IS NOW A TAB IN CAF. SO WHEN YOU LOG OUT OF CAF, YOU LOG OUT OF EVERYTHING.