Patient Safety Mini-Wargame Calls for Greater Collaboration Across Health Disciplines
Exercise brought key stakeholders together to help discover common-ground solutions for addressing preventable medical errors.
McLean, VA, February 23, 2004 — In a strategic simulation of medical errors involving hospitalized patients — caused by a dosage error and a network computer virus — a group of healthcare providers and administrators found that over-reliance on rudimentary, vulnerable IT systems and a lack of collaboration among stakeholders could be major contributing factors to the thousands of preventable patient deaths each year. The group focused on ways to improve technology use, communications, contingency planning, and involvement of a broad spectrum of stakeholders.
The Patient Safety mini-Wargame, sponsored by Booz Allen Hamilton, took place at one of the HIMSS pre-conference workshops on February 22, 2004, with 25 participating leaders from healthcare provider organizations who have a critical stake in patient safety.
In the wargame scenario, a four-year-old pediatric intensive care unit patient received an incorrect dosage of morphine while under hospital care. A second scenario involved a computer virus that caused lab results to be attributed to the wrong patient, resulting in the death of another patient.
Wargame participants were from a range of private hospitals, hospital administration staff, doctors, nurses, hospital systems engineers, lawyers, technology providers, consulting, and patient advocacy groups. All grappled with ways to provide critical patient care while maintaining an open and efficient patient treatment system. Key lessons learned included the following:
- There is an over-reliance on IT due in part to staffing shortages and task saturation in highly intense clinical environments. This over-reliance is further propagated by a culture that favors technology.
- Healthcare IT systems today are rudimentary and do not adequately accommodate complex order entry, which require more checks and balances than the technology yet offers, and lack sufficient heuristics.
- Accountability extends beyond the IT system. The interwoven dependencies among the people, processes, and technology of a hospital system need to work in harmony for patient safety. Cross collaboration among physicians, nurses, administrators, and IT is needed to deliver effective healthcare IT and improve patient safety.
- Inclusion of patients in medical error analyses is critical. Despite the importance of the patient perspective, patient advocate roles are not clearly defined, which can be a barrier to two-way communication. Communication with the patient or the patient's family must provide compassionate full disclosure.
- There is a systemic lack of awareness of the vulnerability of healthcare IT systems to computer viruses, highlighting a need for hospitals to re-examine their contingency plans and downtime procedures.
"The game revealed that patient safety is everyone's concern, and the responsibility of every stakeholder," said Booz Allen Vice President Susan Penfield. "Key steps to providing reliable patient safety are to look at the problem holistically, and to open a constructive dialogue between stakeholders."
"Wargaming is a powerful process for thinking about the future, which challenges conventional wisdom and allows participants to break with known truths and past assumptions," adds Booz Allen Senior Associate Mark Frost. "The goal of the Patient Safety mini-Wargame was to provide HIMSS participants with a sampling of the techniques that can be employed to address critical healthcare issues," he said.
Wargame participant John Walter of The Market Tech Group noted that "exposing and contrasting actions by different stakeholders proved enlightening. Consolidating the process into 90 minutes from the usual 3 months it would take in the real world helped participants gain valuable perspectives."
Dr. Sanjaya Kumar, Chief Medial Officer of Quantros found the wargame to be "very beneficial, sparking thought on how to apply the lessons learned from the game. Getting the different teams thinking together was extremely useful — it can be unusual in the normal work environment."
Penny Schaefer, a registered nurse, also took part in the wargame. "The realism of including patients enhanced the experience. It really drove home the importance of a systems perspective that is often overlooked when analyzing patient safety."
Booz Allen is a leader in developing wargames for both public and private sector clients. Booz Allen has developed its unique brand of wargaming as a means to help our clients "experience the future" before committing the organization, its people, resources, and reputations, to a course of action where there is no turning back, according to wargaming expert Mark Frost.
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