Chapter 50. Patient Care Technology and Safety 

Gail Powell-Cope, Audrey L. Nelson, Emily S. Patterson 

Background 

The general public believes that technology will improve health care efficiency, quality, 

safety, and cost. However, few people consider that these same technologies may also introduce 

errors and adverse events.1

 Given that nearly 5,000 types of medical devices are used by millions 

of health care providers around the world, device-related problems are inevitable.2 While 

technology holds much promise, the benefits of a specific technology may not be realized due to 

four common pitfalls: (1) poor technology design that does not adhere to human factors and 

ergonomic principles,3

 (2) poor technology interface with the patient or environment,3 (3) 

inadequate plan for implementing a new technology into practice, and (4) inadequate 

maintenance plan.4 

Patient care technology has become increasingly complex, transforming the way nursing care 

is conceptualized and delivered. Before extensive application of technology, nurses relied 

heavily on their senses of sight, touch, smell, and hearing to monitor patient status and to detect 

changes. Over time, the nurses’ unaided senses were replaced with technology designed to detect 

physical changes in patient conditions.5

 Consider the case of pulse oxymetry. Before its 

widespread use, nurses relied on subtle changes in mental status and skin color to detect early 

changes in oxygen saturation, and they used arterial blood gasses to confirm their suspicions. 

Now pulse oxymetry allows nurses to identify decreased oxygenation before clinical symptoms 

appear, and thus more promptly diagnose and treat underlying causes. 

While technology has the potential to improve care, it is not without risks. Technology has 

been described as both part of the problem and part of the solution for safer health care, and 

some observers warned of the introduction of yet-to-be errors after the adoption of new 

technologies.6 For example, nurses and other health care providers can be so focused on data 

from monitors that they fail to detect potentially important subtle changes in clinical status. 

Problems may emerge based on the sheer volume of new devices, the complexity of the devices, 

the poor interface between multiple technologies at the bedside, and the haphazard introduction 

of new devices at the bedside. Despite the billions of dollars spent each year on an everincreasing array of medical devices and equipment, the nursing profession has paid little 

attention to the implementation of technology and its integration with other aspects of the health 

care environment. 

Patient care technologies of interest to nurses range from relatively simple devices, such as 

catheters and syringes, to highly complex devices, such as barcode medication administration 

systems and electronic health records.7

 Technology can be broadly defined to include clinical 

protocols and other “paper” based tools, but for the purpose of this chapter, we will focus more 

on equipment and devices that nurses are likely to encounter in delivering direct care to patients. 

The purpose of this chapter is to provide a conceptual model for technologies that nurses are 

likely to encounter and to delineate strategies for promoting their effective and safe use. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Conceptual Framework 

Based on a review of the literature, a conceptual framework was developed that depicts the 

relationship among the nurses’ use of technologies; moderating and mediating factors that affect 

use; and the potential nurse, patient, and organizational outcomes (Figure 1). This model was 

developed independently, but is similar to the work of Fuhrer and colleagues,8 whose framework 

of assistive technology device outcomes is patient-centric. We included key nursing processes 

and outcomes for which technology plays an important role in care delivery and in preventing 

adverse events. 

Outcomes

Long Term 

Outcomes

Patient

Adverse events

Injuries

Satisfaction

Nurse

Satisfaction

Competency

Errors

Goal Attainment

Organizational

Efficiency

Healthcare Quality

Nursing Retention 

and Recruitment

Nursing Processes

Initial Use by Nurse for:

• Direct Nursing Care Delivery

• Indirect Nursing Care Delivery

• Patient and Nurse Protection from Harm

• Patient Assessment, Monitoring, and 

Surveillance

• Patient Assistance

• Remote Patient Monitoring

• Communication

• Continuous Learning

• Pattern Identification

Identification 

and 

Procurement 

of 

Technology

Technology

Moderating and Mediating Factors

Organizational Factors ( policies, resources, culture, social norms, management commitment, training 

programs, employee participation/empowerment, ethical environment)

Social Factor: Characteristics of Nurse (age, experience, mindset about technology/attitudes, selfefficacy, attention, fatigue, sensory input, perception, goals, intention to use, knowledge)

Social Factor: Characteristics of Patient (age, co-morbidities, attitudes, receptivity, sensory capabilities)

Physical Environment (lighting, noise, architectural features)

Characteristics of Technology (reliability, validity, ergonomic design, output display, input mechanism, 

interface, compatibility with other technologies)

Figure 1. Conceptual Model for Technology, Nursing, and Patient Safety

Initial Outcomes

Effectiveness

Efficiency

Device 

Satisfaction

Patient 

Satisfaction

Continued 

Use by 

Nurse

Discontinue 

Use

Discontinue 

Use

Continued 

Use by 

Nurse

This conceptual model places the use of technology in the context of nursing practice and 

offers a framework for examining both the short- and long-term outcomes of technology use on 

the patient, the nurse, and the organization. Fuhrer’s model focused on assistive technologies, 

that is, a spectrum of interventions—including structural and nonpermanent alterations of the 

physical environment, equipment attached to the physical environment, devices used by 

individuals, and behavioral modification—for promoting independence and function with a 

disability. This model is extended to include a full range of technologies used by nurses in the 

delivery of nursing care (Table 1). Patient care technologies can be classified in many ways. 

These technologies are categorized by commonly understood nursing activities: direct nursing 

2 
Patient Care Technology & Safety

care delivery technology, indirect nursing care delivery technology, communication technology, 

patient and nurse protective devices, nurse protective devices, patient assessment, monitoring 

and surveillance, patient assistive devices, remote monitoring, continued learning, and pattern 

identification. Well-designed technology allows nurses to focus on caregiving functions and 

promoting the health of patients. 

Table 1. Technology Commonly Used by Nurses

Indirect Nursing Care Delivery 

Technology 

Robotics 

Radio frequency identification 

Electronic inventory systems 

 Computerized staffing systems 

Communication With People 

Distanced by Place and Time 

Electronic medical records 

Electronic ordering systems 

Communication devices (cell 

phones, PDAs, “Voicera,” 

paging systems) 

Call systems, including emergency 

call bell 

Direct Nursing Care Delivery 

Technology 

Barcode medication administration 

Intravenous (IV) tubing 

IV pumps 

Feeding pumps 

Nasogastric tubes 

Endotrachial tube 

Tracheostomy tubes 

Syringes 

Needles 

Urinary catheters and drainage 

bags 

Ostomy appliances 

Wound drainage tubes 

Chest tubes 

Suction equipment 

Oxygen and air regulators, tubing, 

and face masks 

Oxygen tanks and regulators 

Nebulizers 

Dressings (from gauze to 

specialized materials) 

Traction systems 

Code carts 

Patient Protective Devices 

Floor mats 

Beds 

Elopement/wandering alarms 

Fall alarms 

Hip protectors 

Specialized mattresses (e.g., low 

air loss) 

Specialized lighting 

Hand rails in patient rooms, 

hallways, and bathrooms 

Specialized seating cushions 

Limb compression devices 

Patient Assessment, Monitoring, 

and Surveillance 

Telemetry 

Bedside monitoring 

Ventilators 

Video surveillance 

Stethoscope 

Sphygmomanometer 

Thermometer 

Otoscope 

Ophthalmoscope 

Pulse oxymetry 

Nurse Protective Devices 

Face masks 

Gloves 

Gowns 

Hand sanitizer dispensers 

Mechanical lifts 

Patient transfer devices 

Remote Patient Monitoring 

Telemedicine and telehealth 

Patient Assistive Devices 

Canes 

Walkers 

Robotics 

Stand assist lifts 

Trapeze bars 

Patient transfer devices ECD 

Bed pans 

Wheelchair 

Prosthetic limbs 

Orthotics (braces, shoes) 

Continuous Learning 

Distance learning 

Video conferencing 

Online training 

Pattern Identification 

(To learn from errors and systems 

influences on adverse events) 

Electronic medical records 

Workload and staffing data systems 

According to Stone and Wiener,9 workplaces have four dimensions: (1) organizational 

arrangements, for example, goals, structure, policies, and rewards; (2) social factors, for 

example, organizational philosophy and values, management style, and interactions with 

employees and patients; (3) the physical setting/environment, for example, character, physical 

design, and ergonomics; and (4) technology. In our proposed model, these workplace dimensions 

affect the nurses’ initial and continued use of technology. 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Technology 

Technologies used by nurses offer the means for preventing errors and adverse events (e.g., 

medication errors, miscommunications, delays in treatment, and adverse events—such as failure 

to rescue, nosocomial infections, pressure ulcers, falls, and complications of immobility). Yet 

technology also introduces unintended side effects and opportunities for failures.6

 In a chart 

review, Samore and colleagues10 found that devices most commonly associated with adverse 

events were foley catheters (57 percent of adverse events involving devices), arterial catheters 

(17 percent of such events), central venous catheters (17 percent of such events), and 

peripherally inserted central catheters (7 percent of such events)—all devices used by nurses in 

the direct care of patients. At one pediatric hospital, implementation of a computerized provider 

order entry system intended to reduce handwriting and transcription errors was unexpectedly 

associated with increased mortality, presumably due to a reduced ability by nursing personnel to 

anticipate the needs of patients prior to arrival of the patient.11 Other research showed that 

although barcoding medication administration was believed by most nursing personnel to 

decrease medication errors, it was also believed to reduce the ability for physicians to review the 

accuracy of medication administration and decrease the ability to deviate from routine 

medication administration sequences.12 In another example, a few years ago, in an effort to 

prevent hip fractures from falls from bed, some nursing homes used non-height-adjustable low 

beds. This solution for preventing hip fractures among residents, however, forced nursing staff to 

provide care on their knees or bent over, thus increasing staff risk for back and knee injuries. 

Green13 noted that all injuries and unintended consequences of technology are impossible to 

know beforehand, and that they are an unavoidable aspect of technology development. In other 

words, without technology failures there cannot be progress in technology development. 

Nurses may respond to unintended consequences of technology with “work-arounds,” or 

temporary fixes to technology problems or malfunctions. While work-arounds fix an immediate 

problem at hand, work-arounds can be dangerous, not solving the underlying problem in a 

system,14 and thereby increasing opportunities for error over time. For example, in early 

implementation of barcode administration, scanning devices that were attached to the medication 

cart with a cord often made it difficult for nurses to scan the patients’ identification arm due to 

infection control restrictions. In response, nurses made duplicate arm bands that they kept at the 

medication cart. The duplicate bands allowed for ease in scanning, yet doing so bypassed the 

safety feature that required a positive patient identification (by scanning the band on the arm) 

before administering a medication and increased the likelihood of “wrong patient” errors. When 

this work-around was discovered by an independent evaluator, nursing worked with the vendor 

and infection control experts to use disposable plastic covers to scan infectious patients.15, 16 

Organizational Factors 

Organizational factors that influence the use of technology include policies, resources, 

culture, social norms, management commitment, training programs, and employee 

empowerment. It has been noted that the effects of implementing technology—for example, 

information technology—can vary widely depending on the setting,17 presumably due to 

differences in the social-organizational environment such as workflow, work tasks and 

processes, and the people in the environment. Policy is often looked at as an effective means for 

implementing change. For example, when implementing safe patient movement and handling 

4 
Patient Care Technology & Safety

programs, it is helpful to have firmly established leadership and management support, 

equipment, training, and coordination with other departments before mandating mechanical 

lifting through policy.18 Policy hastily implemented before consideration of the impact of 

technology can result in staff averting the policy and risking the consequences or staff appearing 

to be in compliance with the policy when they are not. Both of these situations can adversely 

affect staff morale and satisfaction. 

Social Factors 

Sandelowski19 noted the complex and often troubled relationship between technology and 

nursing since the establishment of nursing as a profession in the latter part of the 19th century. 

Nurses have been both users of technology and facilitators for gaining patient acceptance of 

technology, but it has sometimes been a struggle for nurses to define the role of technology in 

their profession. Technology has played out in the debates of caring versus curing and hightouch versus high-tech in explaining the role of nursing in health care. In the 1970s, the mastery 

of technology often took second place after the mastery of psychosocial skills such as 

communication and development of a therapeutic relationship. This relatively recent culture of 

nursing and the culture of health care have in many instances served to work against the 

systematic incorporation of technology into nursing practice to improve patient outcomes. Using 

a Heideggerian analysis of technology, Zitzelsberger20 proposed that the usual ways in which we 

perceive technology in terms of function, utility, and positive outcomes overshadow other 

“modes of revealing,” so that nurses and other health care personnel are likely to accept 

technology and incorporate it into practice without critical evaluation of its benefits and 

problems. For example, why is it that nursing that requires higher levels of technology, as in 

critical care, is valued more (e.g., paid more) than nursing that requires little technology, as in 

the personal care of residents in a nursing home? 

Certainly, characteristics of nurses will affect the adoption of technology, although little 

empirical evidence was found to document this phenomenon. Nurses have been found to be 

willing to embrace safe patient handling and other technologies if they are convenient; easy to 

use; target a high-risk, high-cost, and high-prevalence problem (such as falls); are consistent with 

unit and/or organizational goals; and are either compatible with existing work patterns or have 

the potential for improving efficiency and time spent with patients. It is likely that nurse 

characteristics that influence the use of technology are specific to the technology in question. For 

example, in a study of implementation of a nursing documentation information technology 

system, the investigators found that adoption was influenced by a number of attributes of the 

nurses, including commitment to nursing care planning and written documentation, acceptance 

of computers in nursing, computer and typing skills, professional experience, level of motivation, 

and climate of trust and support within the nursing team.17 

Physical Environment 

The physical environment, particularly in older buildings that were never designed to 

accommodate newer technologies, is often a constraining factor in the use of many types of 

equipment used by nurses. For example, research has shown that an ergonomic approach that 

relies on equipment to promote safe patient handling decreases musculoskeletal injuries in 

nurses.21 The environment is critical in the nurses’ use of this equipment because if the 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

equipment is not readily accessible, the nurse will be less likely to use it. If the patient handling 

equipment is located at the end of a hallway in a room behind other equipment, the nurse is less 

likely to use it than if it is stored in an open alcove in the hallway where it can easily be 

retrieved.22

Mediating and Moderating Factors 

Ergonomics and human factors engineering offer useful frameworks for examining many of 

the mediating and moderating factors (e.g., the user/technology interface) that will affect use of 

the equipment and outcomes of its use. According to the International Ergonomics Association,23 

Ergonomics (or human factors) is the scientific discipline concerned with the 

understanding of interactions among humans and other elements of a system, and 

the profession that applies theory, principles, data and methods to design in order 

to optimize human well-being and overall system performance. 

Ergonomists contribute to the design and evaluation of tasks, jobs, products, 

environments and systems in order to make them compatible with the needs, 

abilities and limitations of people. 

According to Gosbee24 (p. 3), “Human factors engineering is the discipline concerned with 

understanding human characteristics and how humans interact with the world around them and 

the application of the knowledge to the design of systems that are safe, efficient and 

comfortable.” Without a complete understanding of human factors, the tendency is to focus on 

human failures as the major source of error, and to focus attention on automation of tasks to 

prevent errors. Several problems with this approach are evident: 4 

• By taking away the easy parts of the job, automation can make the difficult aspects of the 

job more difficult. 

• While humans are known to be fallible, we leave staff to cope with tasks the designers 

could not figure out how to automate, most important, the job of restoring the system to a 

safe state after a failure. 

• Humans are expected to “monitor” the automated processes, even though we know 

vigilance is not likely when abnormal events are relatively rare. 

• Skills need to be practiced continuously to preserve them, yet the occasional system 

failure denies the staff the opportunity to practice the skills needed in such an emergency. 

• Nurses are generally not exposed during educational programs and on the job to 

engineers, biomedical engineers, industrial designers, and ergonomists, the designers of 

the equipment they use in providing care. 

Because nurses work at the front lines of health care—where nurses, patients, and 

technologies intersect and where actions are highly visible—there is a tendency to blame these 

frontline workers for human error associated with technology failures. Reason4

 called these 

“human operator problems,” which can be classified at the individual or systems level. Examples 

of individual-focused problems include deficient procedures or documentation, lack of 

knowledge or training, failure to follow procedures, and deficient planning or scheduling. 

Systems-oriented problems include miscommunication, deficient supervision, and policy 

problems. Technology failure should be viewed in the broader context of the complex health care 

system, rather than inappropriately blaming the individual nurse. 

6 
Patient Care Technology & Safety

Outcomes of Technology Use

As Fuhrer and colleagues8 noted, a paucity of outcome measures is a significant barrier to the 

conduct of outcomes research related to technology. The lack of conceptualization of outcomes 

in the context of the type of technology and its context of use is added. The key initial outcomes 

of technology are effectiveness, efficiency, and user (i.e., nurse) and patient satisfaction with the 

device. Verza and colleagues25 specifically examined “equipment abandonment,” that is, the 

disuse of a previously obtained device, in the context of assistive devices for persons with 

multiple sclerosis. They found that abandonment could be reduced by an interdisciplinary 

prescribing approach. 

Longer-term objectives reach beyond these immediate ones and include adverse events, 

injuries, satisfaction, competency, errors, goal attainment, and organizational outcomes such as 

efficiency, cost (including cost avoidance, return on investment, margins, and working capital),26

health care quality, and nursing retention and recruitment. Karwowski,27 in building a model of 

ergonomics, differentiated positive outcomes (e.g., improved work productivity, shorter 

performance times, improved product quality, and desirable psychological and behavioral 

outcomes) from negative outcomes (e.g., loss of productivity, low quality, accidents, injuries, 

and undesirable physiological and psychological outcomes). 

Optimally, technology is designed to minimize errors and buffer the consequences of errors1

by (1) eliminating errors and adverse events; (2) reducing occurrence of errors/adverse events; 

(3) detecting errors early, before injury occurs; and (4) mitigating the effects of errors after they 

occur to minimize injury.3 In this “ideal” scenario, patient care technology would yield positive 

nurse, patient, and organizational outcomes. Consider all of the alarms and warning systems used 

in the delivery of nursing care to detect errors before injury. A partial list includes bed exit 

alarms, warnings on IV pumps that signal occlusions, patient-initiated call bells, staff-initiated 

code alarms, wandering and elopement alarms, cardiac monitor alarms, and ventilator alarms. All 

of these warning systems depend on the ability of the nurse to notice the warning, process the 

alarm and comprehend what is happening, and finally take the appropriate action to decrease risk 

to the patient.28 In one recent study, medical/surgical nurses wanted “smart monitoring devices” 

that interfaced with the electronic medical record as well as with wireless communication 

devices.29 However, this strategy of using automated alarms is challenged by “alarm fatigue” 

stemming from the sheer number of alarms. Further, alarm fatigue is exacerbated by the wellintentioned, yet misguided decision to deliberately set alarms with a high false alarm rate; the 

effectiveness of an alerting signal drops precipitously with just a small number of false alarms.30

A significant difference in the model presented here from Fuher’s8

 is that both nurse and 

patient outcomes are included. In addition to the potential physical harm from technology, Monk 

and colleagues31 proposed that for older adults living with disabilities in their homes, 

psychological harms are as important as the physical ones. These researchers argued for 

including three types of physical harm (injury, untreated medical condition, and physical 

deterioration), four types of psychological and social harm (dependency, loneliness, fear, and 

debt or poverty), and four generic consequences (distress, loss of confidence in ability to live 

independently, costly medical treatment, and death) for systematically evaluating technology 

used to promote independent living. 

While patient care technology offers many opportunities to improve nurse productivity and 

satisfaction, operational efficiency, patient satisfaction, safety, and quality, there is little research 

evaluating the outcomes of specific patient care technologies. Barcoding, scanning, and robotics 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

have been shown to improve efficiency and decrease costs.32 The Veterans Health 

Administration (VHA) has successfully implemented barcode medication administration 

software. This innovative automated system uses a wireless, point-of-care technology with an 

integrated barcode scanner. The system can dramatically reduce medication administration errors 

by letting clinicians verify a patient’s identity and validate medications against active orders. 

After implementation at the Kansas VA hospital, the VHA estimated that the software prevented 

549,000 errors while dispensing 8 million doses.32 In a quality improvement project, Bahlman 

and colleagues33 found that implementation of an integrated communication system in an 

operating room had a positive effect by reducing staff time for phone calls to relay messages; 

reducing time nurses had to spend hunting pieces of equipment; enabling more timely 

administration of antibiotics for total joint procedures; improving communication with family 

members about progress of the patient through preoperative, operative, and postoperative care; 

and providing a quieter environment due to less overhead paging and the use of vibration modes 

for wireless telephones. 

Moderate evidence is available supporting use of electronic medical records and automated 

drug-dispensing machines, with reports of increases in nurse satisfaction, retention, and 

productivity, as well as decreases in errors.32 Despite the limited research available to support the 

benefits of technology, a recent Institute of Medicine report identified use of information 

technologies to automate clinical information as one of the keys to safer, quality health care 

systems.34 

Practice Implications 

Being informed consumers and users of technology in health care means that nurses be 

involved in the selection of new equipment, receive the proper training for its use, and monitor 

equipment safety and the effect of technology on patients and families on an ongoing basis. 

Selecting the wrong equipment and technology can be costly and expose the patient to 

errors.35 Even when optional equipment/technology is selected, if it is not well integrated into the 

current delivery system, or it is implemented in a chaotic way, this can result in unexpected costs 

and increased errors.35 In choosing the best equipment for the task at hand, we found ergonomicbased and social-marketing approaches extremely beneficial. An ergonomic assessment, 

focusing on the user/equipment interface, involves asking nurses to test equipment and provide 

feedback on usability, safety, and patient acceptance. Equipment fairs are one strategy to allow 

staff the opportunity to evaluate which brand or model of technology would work best in their 

setting. Manufacturers are usually willing to loan equipment to promote onsite clinical testing. 

From a social-marketing perspective, all stakeholders potentially affected by a device should be 

invited to participate in equipment trials.36 Different user groups will have different perspectives 

and requirements of the equipment. For example, in evaluating a hospital bed, a patient may 

focus on comfort, a biomedical engineer may focus on compatibility with other technologies and 

the ease of maintaining the bed in good working order, and a nurse might focus on the usability 

of special features such as built-in scales and bed exit alarms. Once a purchasing decision is 

made, including input from staff nurses, training is critical and may require ongoing competency 

assessments over time.35 

The World Health Organization Medical Devices and Equipment team described a life-cycle 

approach that systematically includes maintenance, training, monitoring, and vigilance reporting 

on medical devices in use.37 Through surveillance, nurses play an important role in early 

8 
Patient Care Technology & Safety

identification and correction of latent errors related to technology. Staff who operate equipment 

and are trained in its use can recognize maintenance problems and request timely maintenance.38

Similar to the notion of patient surveillance to detect errors early and prevent adverse events3 (p. 

91), equipment surveillance means that nurses conduct purposeful and ongoing data collection to 

identify malfunctioning and broken equipment, interpret data that indicate equipment problems 

to determine the source of error, and act based on the interpretation by quickly and directly 

responding or appropriately reporting and following up. 

The Safe Medical Devices Act of 1990, which became effective in 1991, requires (italics 

added) health care facilities to report to the manufacturer and/or the Food and Drug 

Administration (FDA) all incidents that reasonably suggest that the medical device might have 

contributed to a death or serious injury or illness. Nurses should be familiar with internal systems 

of reporting, as well as the FDA medical device reporting (MDR) system (available at 

http://www.fda.gov/medwatch/how.htm). MDR is the mechanism by which the FDA receives 

information about medical device adverse events from manufacturers, importers, and user 

facilities, so any problems with the device can be detected and corrected. ECRI Institute 

encourages the reporting of device-related incidents and deficiencies to determine whether a 

report reflects a random failure or one that is likely to recur and cause harm. (Reports can be 

submitted to ECRI’s Web site at http://www.ecri.org/PatientSafety/ReportAProblem/Pages/ 

default.aspx.) Health care failure mode effect analysis39 and sociotechnical proactive risk 

modeling40 offer methods for identifying equipment failures before they happen and strategies 

for preventing them. Both of the methods have been used in engineering, and both are 

prospective in that they can be used to identify and prevent product and technology-related 

problems before they occur. Proponents of proactive risk modeling methods, relatively new to 

health care,40 suggest that nurses could play an active role in preventing equipment and 

technology failures and in responding appropriately to them should they occur. 

Risk modeling, an established analytic method in high-risk industries such as aerospace and 

engineering, is a structured process of determining all the ways a failure can happen to identify 

likely prevention strategies. Proactive risk modeling has been described as a hybrid between 

traditional decision support models and process analysis techniques (e.g., root-cause analysis, 

failure modes, and effects analysis),41 designed to address rare adverse events associated with 

high mortality and high costs. For example, after installation of mobile patient lifts into a facility, 

nurses may anticipate that they would be forced to perform manual lifts, putting themselves at 

high risk for a lifting injury, if all of the backup battery packs were not fully charged, rendering 

the electric lifts useless. In naming all of the ways this could happen, a group of nurses would 

identify processes that, if in place, would avoid the failure of charging batteries, for example, 

buying extra battery packs or plugging in equipment after each use. Competency checklists could 

be used to reinforce this process and ensure that everyone is performing it in the same way. 

Alternatively, the nurses may opt for an alarm system that notifies them when a battery’s charge 

is running low and does not stop alarming until it is plugged into the electrical outlet to charge. 

Nurses could be proactive in equipment use by discussing “what if” scenarios to determine 

useful responses in the event of equipment failures. For example, a group of nurses could be 

asked to discuss what they would do if a patient became stranded in a ceiling lift that would not 

lower back down to the bed. After such a discussion, nurses would be in a better position to 

respond if that event were to occur than if they had not anticipated this possibility. 

Nurse educators could advance the role of nurses in the use of technology by providing 

human factors content into nursing curricula and including human factors engineers into newer 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

interdisciplinary approaches to professional education. An engineering perspective views safety 

as a feature that needs to be “engineered” into technology and that human errors emerge from the 

human/machine interface. Equipment misuse is viewed as a failure of the designer to tailor the 

system appropriately to the cognitive strengths and weaknesses of human users.4

 Human factors 

engineering and good design can help trap failures so the end result is not a bad outcome,42 and 

good design can be facilitated by more informed and sophisticated users. Nurses need to operate 

as though just because a technology is commercially available does not mean it is good. In our 

experience, manufacturers welcome feedback from nurses because it allows them to make design 

changes that not only improve patient safety, but also make products more marketable to nurses. 

Gosbee42 suggested that nurses can be trained to more easily detect human factor design issues 

instead of dismissing them as human error or “somebody else’s job.” 

Implementation of new technologies offers nurses yet another avenue for ensuring safe and 

efficient use of technology (Table 2). In our experience, we have found that staged 

implementation is often desirable, because it allows for formative evaluation that can be used to 

improve the implementation process. Staging also minimizes overload associated with training 

and behavioral changes. From the literature on research translation and our own experiences, 

clinical champions, local opinion leaders,43 or “super users” of equipment may greatly facilitate 

smooth implementation of new equipment. These clinical leaders are most effective when they 

are respected by coworkers and perceived by coworkers as knowledgeable, clinically competent, 

and accessible. Clinical leaders can offer on-the-spot training, encouragement, advice, and 

troubleshooting expertise to other staff as workers are learning to use new equipment. 

Table 2. Tips for Nurses To Influence Technology at the Bedside 

• Organize equipment fairs to gain input from key users and stakeholders before purchases. 

• Examine performance of technology on challenging scenarios in a simulated setting with a small 

number (three to five) of untrained, representative users.44

• Mentor and oversee temporary (agency) nurses and other personnel (e.g., resident physicians) during 

first-time use of sophisticated technology. 

• Develop cogent arguments to administration to justify purchase of new equipment and technologies, 

balancing the cost of equipment (costs of purchase, training, and maintenance) against costs saved if 

equipment was not purchased. 

• Become critical users of technology by identifying problems early and communicating them to vendors 

and in-house biomedical engineering staff. 

• Report adverse events associated with medical devices to the Food and Drug Administration MAUDE 

reporting system and/or ECRI’s Problem Reporting System.45

• Serve as a resource person on your unit for new technologies by getting training early, communicating 

with vendors, training others on your unit, and offering to field questions as new technology is 

implemented. 

Research Implications 

As previously described, there are a number of moderating and mediating factors for how 

useful technology is in practice. Appropriately addressing these factors will require collaboration 

across a number of disciplines. Clinical experts are needed to provide critical input into the 

design and application of technologies in health care. Direct patient care nurses need to be 

actively involved in the design and testing of technology. Human factors experts aid in 

integrating technology into existing workflow and in making interfaces easy to learn and use 

under stressful conditions. 

10 
Patient Care Technology & Safety

It has been suggested that some of the mismatches between device design and health care 

settings might stem from a more fundamental disagreement about the nature of work.46 An area 

for further study is whether the implicit theories of work by designers and managers are 

oversimplified in relation to the actual work setting, and whether these oversimplifications doom 

technologies to fail regardless of how usable the interface is or how many clinical experts have 

provided input during the design, procurement, implementation, and maintenance phases. 

A major barrier to widespread use of technology is cost. Further research is needed to build a 

business case for use of technology, including return on investment and cost-benefit analyses.35

Proactive assessment of key stakeholder perceptions of the technology is also essential, including 

end-users (nurses and others directly involved) as well as patients and their families.35

Chaotic implementation of new technologies appears to be the norm in health care. More 

research is needed to more effectively introduce new technologies, minimizing risk to the 

patient, and reducing stress on nursing staff. Likewise, once technology is integrated into nursing 

care delivery systems, adequate maintenance programs are needed. 

Specific research priorities include the following: 

1. There is a paucity of research evaluating the outcomes of specific patient care 

technologies. Further research is needed to evaluate the immediate and long-term 

outcomes associated with specific technologies used in nursing practice. Research should 

include nursing, patient, and organizational outcomes. 

2. Nursing practices and care delivery systems vary across sites. Further research is needed 

to evaluate the effects of various nurse processes and environmental conditions on the 

use, effectiveness, and efficiency of specific technologies used in nursing practice. 

3. There are a number of moderating and mediating factors affecting technology use in 

health care (e.g., organizational factors, social factors, physical environment, and 

characteristics of technology). Further research is needed to examine these mediating and 

moderating factors and how they affect both the use of technology and outcomes. 

4. Variations in how technologies are implemented exist across organizations and practice 

settings. Research is needed to improve the processes for introducing technology into the 

workplace to optimize outcomes. 

5. Given that a major barrier to widespread use of technology is cost, further research is 

needed to build a business case for use of specific technologies, including return on 

investment and cost-benefit analyses. 

6. Because learning from errors and near misses is critical for building an effective culture 

of safety, research should be conducted to identify effective ways to learn from 

equipment-related adverse events across practice sites. 

7. Research and development needs to focus on how to best integrate multiple technologies 

into patient care to maximize outcomes and decrease burdens on nurses. 

8. Recognizing the inordinate amount of time nurses spend in performing indirect or 

nonnursing care, research is needed to evaluate the effect of technologies designed to 

reduce the time spent on nonnursing tasks (such as hunting and gathering supplies) and in 

indirect nursing care activities (such as documentation) to maximize the time nurses can 

spend in providing direct patient care. 

Other considerations are: 

1. What are the most critical challenges to successfully implementing new technologies into 

health care environments and nursing practice? 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

2. How do nurses serve as the last line of defense in protecting the patient from harm 

associated with technology? 

3. What are the opportunities for nurses at the bedside to become involved in technology 

design and testing? 

Conclusions 

Research on the quality of care reveals a health care system that frequently falls short in its 

ability to apply new technology safely and appropriately.34 Workplaces, instruments, and 

equipment can be developed according to human factors design criteria,47 but as an end-user, 

nurses can maximize safety through the selection process, ongoing surveillance of equipment, 

and proactive risk-assessment methods. 

The approach offered for nurses is consistent with the following four-pronged strategy 

developed by the World Health Organization Medical Devices and Equipment team:37

• Policy: Nurses providing direct patient care should be involved in setting and evaluating 

institutional, organizational, and public policy related to technologies. 

• Quality and Safety: Nurses providing direct patient care can ensure that the technologies 

they use meet international quality and safety standards and technical specifications 

needed to perform in the clinical environment in which they are used. 

• Access: Nurses providing direct patient care can ensure that institutional decisions are 

made with their input and the input of other critical stakeholders. 

• Use: Nurses providing direct patient care should be involved in their intuitional policies 

and processes related to maintenance, training, monitoring, and reporting adverse events 

related to technology. 

Author Affiliations 

Gail Powell-Cope, Ph.D., A.R.N.P., F.A.A.N., director, Research Enhancement Award 

Program in Patient Safety Technology, James A. Haley Veterans Hospital, Tampa, FL. E-mail: 

gail.powell-cope@va.gov. 

Audrey L. Nelson, Ph.D., R.N., F.A.A.N., director, Patient Safety Center of Inquiry, James 

A. Haley Veterans Hospital, Tampa, FL. E-mail: audrey.nelson@va.gov. 

Emily S. Patterson, Ph.D., research scientist, Industrial and Systems Engineering, Getting at 

Patient Safety (GAPS) Center, Cincinnati VAMC, Ohio State University, Columbus, OH. Email: patterson.150@osu.edu. 

12 
Patient Care Technology & Safety

References 

1. Bogner MS, ed. Human error in medicine. 

Hillsdale, NJ: Lawrence Erlbaum; 1994. 

2. ECRI Institute. Medical device safety reports. 

http://www.mdsr.ecri.org/default.aspx?v=1. 

Accessed March 21, 2006. 

3. Institute of Medicine. Keeping patients safe: 

transforming the work environment of nurses. 

Washington, DC: The National Academies Press; 

2004. 

4. Reason J. Managing the risks of organizational 

accidents. Burlington, VT: Ashgate Publishing 

Company; 1997. 

5. Reason J. Human error. London: Cambridge 

University Press; 1990. 

6. Nadzam DM, Mackles RM. Promoting patient 

safety: is technology the solution? Jt Comm J Qual 

Improv 2001;27:430-6. 

7. Hyman WA. Errors in use of medical equipment. 

In: Bogner MS, ed. Human error in medicine. 

Hillsdale, NJ: Lawrence Erlbaum; 1994.:327-347. 

8. Fuhrer MJ, Jutai JW, Sherer MJ, et al. A framework 

for the conceptual modeling of assistive technology 

device outcomes. Disabil Rehabil 2003;25:1243-51. 

9. Stone RI, Wiener JM. Who will care for us: 

addressing the long-term care workforce crisis. 

Bethesda, MD: The Urban Institute and the 

American Association of Homes and Services for 

the Aging; 2001. 

10. Samore MH, Evans RS, Lassen A, et al. 

Surveillance of medical device-related hazards and 

adverse events in hospitalized patients. JAMA 

2004:291:325-334. 

11. Han YY, Carcillo JA, Venkataraman ST, et al. 

Unexpected increased mortality after 

implementation of a commercially sold 

computerized physician order entry system. 

Pediatrics 2005;116:1506-12. 

12. Patterson ES, Cook RI, Render ML. Improving 

patient safety by identifying side effects from 

introducing bar coding in medication 

administration. J Am Med Inform Assoc 2002; 9: 

540-53. 

13. Green SA, The evolution of medical technology. 

Clin Orthop Relat Res 2001;385:260-6. 

14. Koopman P, Hoffman R. Work-arounds, makework, and kludges. Available at: http://www.ihmc. 

us/research/projects/EssaysOnHCC/Kludges&Work

-arounds.pdf. Accessed March 27, 2006. 

15. Patterson ES, Rogers ML, Chapman RJ, et al. 

Compliance with intended use of bar code 

medication administration in acute and long-term 

care: an observational study. Hum Factors 

2006;48:15-22. 

16. Patterson ES, Rogers ML, Render ML. Fifteen best 

practice recommendations to improve the 

effectiveness of bar code medication administration. 

Jt Comm J Qual Saf 2004 Jul;30:355-65. 

17. Ammenwerty E, Iller C, Mahler C. IT-adoption and 

the interaction of task, technology and individuals: a 

fit framework and a case study. BMC Med Inform 

Decis Mak 2006 Jan 9;6:3. 

18. Collins JW. Safe lifting policies. In: Nelson AL, ed. 

Handle with care: a practice guide for safe patient 

handling and movement. New York: Springer 

Publishing; 2005;151-162. 

19. Sandelowski M. Devices and desires: gender, 

technology, and American nursing. Chapel Hill, 

NC: University of North Carolina Press; 2000. 

20. Zitzelsberger HM. Concerning technology: thinking 

with Heidegger. Nursing Philosophies 2004;5:242-

50. 

21. Nelson AL, Baptiste A. Evidence-based practices 

for safe patient handling and movement. Online J 

Issues Nurs 2004;9(3):Manuscript 3. Available at: 

www.nursingworld.org/ojin/topic25/tpc25_3.htm. 

22. Bell F. Ergonomic aspects of equipment: patient 

lifting devices. Int J Nurs Stud 1987;24: 331-7. 

23. International Ergonomics Association. What is 

ergonomics? Available at: http://www.iea.cc/ 

browse.php?contID=what_is_ergonomics. Accessed 

May 18, 2007. 

24. Gosbee JW, Gosbee LL, eds. Using human factors 

engineering to improve patient safety. Oakbrook 

Terrace, IL: Joint Commission Resources; 2005. 

25. Verza R, Carvalho ML, Battaglia MA, et al. An 

interdisciplinary approach to evaluating the need for 

assistive technology reduces equipment 

abandonment. Mult Scler 2006;12:88-93. 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

26. Squires M, Bieslada D, Fanizza R, et al. New 

approaches to improving patient safety: strategy, 

technology and funding. Healthc Q 2005;8(3):120-

2, 124. 

27. Karwowski W. Ergonomics and human factors: the 

paradigms for science, engineering, design, 

technology and management of human compatible 

systems. Ergonomics, 2005;48:436-63. 

28. Wogalter MS. Mayhorn CB. Providing cognitive 

support with technology-based warning systems. 

Ergonomics 2005;48:522-33. 

29. Burns-Bolton L. Technology drill down. Podium 

presentation at the Nurse Work Environment 

Innovation Summit. 2007 Jan 30–Feb1, Oakland, 

CA. 

30. Sorkin RD, Woods DD. Systems with human 

monitors: a signal detection analysis. Hum Comp 

Inter 1985;1: 49-75. 

31. Monk A, Hone K, Lines L, et al. Towards a 

practical framework for managing the risks of 

selecting technology to support independent living. 

Appl Ergon 2006;37:599-606. 

32. Joint Commission on Accreditation of Healthcare 

Organizations. Healthcare at the crossroads: 

strategies for addressing the evolving nursing crisis. 

Author; 2002. 

33. Bahlman DT, Johnson FC. Using technology to 

improve and support: communication and workflow 

processes. AORN J 2005;82:56-73. 

34. Institute of Medicine. Crossing the quality chasm. 

Washington, DC: National Academy Press; 2001. 

35. Nelson AL, Powell-Cope G, Gavin-Dreschnack D, 

et al. Technology to promote safe mobility in 

elderly. Nurs Clin North Am 2004:39;649-71. 

36. Powell-Cope G, Baptiste A, Hoffman S, et al. The 

use of height-adjustable low beds in healthcare. 

(Unpublished manuscript; Sept. 2005).

37. World Health Organization. Medical devices and 

equipment. Available at: http://www.who.int/ 

medical_devices/en/. Accessed March 21, 2006. 

38. Pizzi LT, Goldfarb NI, Nash DB. Making health 

care safer: a critical analysis of patient safety 

practices. Evidence Report/Technology Assessment 

Number 43. (Prepared by University of California at 

San Francisco-Stanford University Evidence-based 

Practice Center under Contract No. 290-97-0013). 

Rockville, MD: Agency for Healthcare Research 

and Quality; July 2001. AHRQ Publication No. 01-

E058. p. 469-79. 

39. DeRosier J, Stalhandske E, Bagian JP, et al. Using 

health care failure mode and effect analysis: the VA 

National Center for Patient Safety’s prospective risk 

analysis system. Jt Comm J Qual Improv 

2002;28:248-67,209. 

40. Battles JB, Kanki BG. The use of socio-technical 

probabilistic risk assessment at AHRQ and NASA. 

In: Spitzer C, Schmocker U, Dang VN, eds. 

Probabilistic safety assessment and management. 

Vol. 4. Berlin: Springer; 2004. p. 2212-7. 

41. Marx DA, Slonim AD. Assessing patient safety risk 

before the injury occurs: an introduction to 

sociotechnical probabilistic risk modeling in 

healthcare. Qual Safe Health Care 2003; 12(Supple 

II): ii33-ii38.

42. Gosbee JW. Who left the defibrillator on? In: 

Gosbee JW, Gosbee LL, eds. Using human factors 

engineering to improve patient safety. Oakbrook 

Terrace, IL: Joint Commission Resources; 2005. p. 

71-75. 

43. Thomson O’Brien MA, Oxman AD, Haynes RB, et 

al. Local opinion leaders: effects on professional 

practice and health care outcomes. Cochrane 

Database Syst Rev. 2000;(2):CD000125. Review. 

44. Patterson ES, Rogers ML, Render ML. Simulationbased embedded probe technique for humancomputer interaction evaluation. Cognition, 

Technology, and Work 2004;6(3):197-205. 

45. Problem Reports: ECRI problem reporting system. 

Health Devices 2002;31:37-8. 

46. Wears RL, Berg M. Computer technology and 

clinical work: still waiting for Godot. JAMA 

2005;293:1261-3. 

47. Van Cott H. Human factors: their causes and 

reduction. In: Bogner MS, ed. Human error in 

medicine. Hillsdale, NJ: Lawrence Erlbaum; 1994. 

p. 53-66. 

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