We hear a lot about the under-reporting of medication errors in hospitals but far less about the impact of erroneous reporting systems on staff morale. The trajectory of my own career might offer some useful insights in how to fix these and other serious healthcare issues.
On my third day as a qualified nurse, I earned a disciplinary hearing. Somehow, I missed administering a daily dose of warfarin to a patient recovering from a hip replacement. Without the essential blood thinning medication, they could have suffered an embolism or died.
I was devastated. In the months that followed, doubt plagued me. How had I made such a critical error?
As it turned out, I hadn’t. I later found out that faults in the hospital’s paper-based record systems caused the mistake. This knowledge brought personal relief, but it did nothing to fix the underlying data problem.
The warfarin incident convinced me that data underpins our industry’s greatest successes and failures. Experiencing its power first hand drove my transition from nursing to clinical informatics.
Now, as a clinical product manager at InterSystems, I spend my days collaborating with colleagues to replace slow, siloed, opaque systems — like the one that earned me my first and only disciplinary hearing — with streamlined ones that harmonise data and processes.
When I work with healthcare organisations to ensure they can make the most of rapidly advancing technology, I reflect on what I learned during a decades-long career in the field. Here are the insights that’ll always stick with me. I hope they help you overcome your next informatics-related challenge.
Data insights improve patient outcomes
A few years after the warfarin incident, I fixed the broken system that caused it. I was working in the healthcare organisation’s clinical audit department, and medication safety was a top priority.
Partnering with the nursing division’s leaders, I implemented a system for logging medication incidents. It was still the early days of computing, so when teams submitted paper reports, I manually entered the information into Excel.
A steady flow of data into the electronic files helped us pinpoint and analyse the issues disrupting care and threatening patients. We found that it wasn’t always clinicians, but poorly managed operational systems, that tended to cause chronic mistakes.
Our innovative use of data mapped so many avenues to enhance medication safety that the hospital hired a full-time employee to implement the changes. The benefits that followed directly resulted from the improved reporting system.
Data provided meaningful insight into our systems that empowered clinicians to improve patient outcomes at scale.
Collaboration unites technology and operations
That initial informatics role grew and soon encompassed oversight of a risk management information system that included medication incidents.
The difficulty of managing the system multiplied with its scope. I wore myself out chasing down incident reports and responding to ad hoc requests. Then it hit me. I couldn’t advance the system alone. It would take site-wide and system-wide collaboration.
I brought everyone together to share our likes and dislikes in group meetings. Together, we determined that our reporting system needed updates. These collaborative feedback sessions ensured that everyone was invested in the system and that managers understood their reporting obligations — critical factors for its success.
The meetings helped us locate blind spots in the design that took a year and a half of work to clear up. They also proved that collaboration could unite technology and operations, allowing healthcare organisations to transform user feedback into efficiencies that bring the true benefits of digital solutions to life.
Active listening is central to success
My career in clinical informatics started with active listening. I learned the term at a conference and, within the year, was studying the field at the Royal College of Surgeons of Edinburgh.
Since then, active listening has been central to my success. It helped me glean insights that led to the development of digital systems to better support practitioner needs. The best example comes from my recent experience implementing the InterSystems TrakCare Advance Program.
To ensure the solution met the demands of more than a dozen hospitals, we created safe spaces where users could share their thoughts and expectations. Then, we combined these findings with data about how they used the system, ultimately creating a report on how to better adopt the solution.
Thanks to the transparent conversations, we prioritised and executed adoption tools and developments that improved the systems for practitioners, streamlining access to insights that clinicians could use to advance care and avoid costly errors.
Data should improve care, not impede it
I can clearly recall my trepidation after the warfarin incident. Without reliable systems to support caregivers, it felt like one decision could lead to countless errors. Pitfalls hid everywhere, and we had no map to help pinpoint them.
Thankfully, we’re building better maps every day. Clinical informatics is dramatically enhancing safety and care for patients while protecting practitioners and patients from unnecessary risk.
I’m proud to have contributed to a healthcare ecosystem where fewer young clinicians must face disciplinary hearings more rightfully attributed to their outdated systems — because data should be a pathway to better care, not an impediment.