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We welcome Ann-Louise Puopolo, a nurse executive, to discuss the critical issue of the nursing shortage crisis and the impact of burnout and technology fatigue on health care workers. Ann-Louise shares insights from her experience at Boston’s Beth Israel Deaconess Hospital, exploring how technology can support the nursing workforce, improve patient care, and promote a culture of safety. We also dive into strategies for empowering nurses to speak up, reducing safety incidents, and leveraging artificial intelligence to streamline workflows and reduce burnout.
Ann-Louise Puopolo is a nurse executive.
She discusses the KevinMD article, “Adopting technology to support the nurse workforce and provide smarter, safer care delivery.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Ann-Louise Puopolo. She’s a nurse executive, and the KevinMD article we’re going to talk about is “Adopting Technology to Support the Nurse Workforce and Provide Smarter, Safer Care Delivery.” Ann-Louise, welcome to the show.
Kevin Pho: Ann-Louise, welcome to the show.
Ann-Louise Puopolo: Thank you for having me, Kevin.
Kevin Pho: So let’s start by briefly sharing your story and journey.
Ann-Louise Puopolo: Sure. I started my career as a critical care nurse in Boston at Beth Israel Deaconess Medical Center and became very interested in health services research. I progressed into looking at medical malpractice and patient safety in the malpractice world as my next frontier.
I worked at CRICO, which is Harvard’s malpractice insurance company. I was the vice president of patient safety. In that capacity, I had the opportunity to meet the organization I currently work with, which is RLDatix. I’m the president of the Safety Institute, and I’ll tell you more about that as we continue our discussion.
But I had the pleasure of meeting RLDatix because all of the hospitals affiliated with Harvard Medical School utilized the safety software that the company provided. In that capacity, we were able to use insights and data to help inform the senior executives who lead these wonderful organizations about where vulnerabilities exist with respect to patient care and where mistakes, unfortunately, lead to medical malpractice and, worse, poor patient outcomes.
I had the privilege, at the end of my career as a patient safety officer, to go to CVS Health, where I ran their enterprise patient safety program across retail pharmacies, minute clinics, mail and specialty pharmacies, infusion, and long-term care facilities. In that capacity, we used data to provide insights into where we could optimize patient care and keep patients free from harm.
In my retirement, I am now at RLDatix, heading an organization called the Safety Institute. In that capacity, we have become listed with the Agency for Healthcare Research and Quality as a Patient Safety Organization (PSO). To remind your audience, the PSO movement started back in 2005 when Congress passed a law allowing us to use data from malpractice mistakes and safety event reporting—as long as we’re not a health insurer—to learn from our mistakes. We’re always looking for ways to address those mistakes in a confidential manner so we can solve these problems, share insights, and improve workflows to prevent the same harms from happening again in the future.
So, it’s a wonderful vehicle for learning.
Kevin Pho: All right. So you wrote the KevinMD article “Adopting Technology to Support a Nurse Workforce and Provide Smarter, Safer Care Delivery.” Tell us what led you to write this article and then talk about the article itself.
Ann-Louise Puopolo: Sure. So, as a nurse and someone involved in the patient safety movement, I’ve noticed, especially in my role on the board at Tufts Medical Center in Boston, that nurses are often not at the table when discussing what goes wrong. And, as the center of the health care ecosystem, it seems like a real miss not to include them, not only to tell us what went wrong but also to be part of the solution. So, I wanted to speak out about nurses being part of the safety movement in their own organizations.
But I also wanted to highlight that without data—and I don’t just mean data that we can’t do anything with, but rather actionable data that serves as real information to show us where our problems are—it’s hard to address those problems effectively. I’m really interested in the idea of connected health operations where we can look at risk, safety, malpractice, credentialing, workforce, and all the various components of the health care ecosystem. If we can glean insights because data has turned into actionable information, we will all be ahead of the curve.
Most importantly, at the end of the day, what I care about is fostering a culture of safety. We need to feel comfortable coming forward in our health care systems, whether you’re a nurse, a doctor, or any other allied health provider, to bring forth vulnerabilities in the workflow that could cause patient harm. If we can talk about it freely and bring it to the attention of our leadership before an accident happens, that better positions us to deliver optimal patient care and keep patients free from harm.
Kevin Pho: When you talk about actionable data that we could use more of, give us an example of what you mean.
Ann-Louise Puopolo: Well, I touched on this a bit in the article. An example is an adverse event in which a nasogastric tube was placed in an emergency room setting after an overdose. Unfortunately, the nasogastric tube didn’t make its way into the esophagus but rather into the patient’s trachea, which led to respiratory distress and landed the patient in the ICU.
When reflecting on what went right versus what went wrong, you’d want to look at the data that suggest, through safety event reporting, how often this has happened. Is there a particular risk time, such as a certain time of day or day of the week? Are the individuals involved in the care properly educated and trained in inserting a nasogastric tube? Was the equipment in good repair? And do we have other intelligence that suggests this is not a one-time problem but rather a recurring issue with similar themes?
Those insights would better position us to address the problem and prevent it from happening again.
Kevin Pho: Do most health care institutions today have similar systems that collect this kind of data? If not, what are some of the barriers that prevent them from implementing such systems?
Ann-Louise Puopolo: We’re fortunate that the patient safety movement and patient safety science have been around for upward of 25 to 30 years. I would say that every health care organization has some ability to report when something goes wrong. But more importantly, the idea of a near miss—where harm didn’t reach the patient—is really where the rubber hits the road.
Unfortunately, the culture is often the impediment to people bringing things forward, rather than the lack of a system to report information. We still have a lot of work to do in advancing a culture of safety around transparency, where there’s no fear of retribution as a result of reporting vulnerabilities in the workflow.
Kevin Pho: You mentioned earlier that culture can be an obstacle. Are you saying that many health care organizations still have a punishment or retribution mentality when it comes to medical errors and patient safety, which prevents them from embracing transparency and adopting technological innovations?
Ann-Louise Puopolo: Unfortunately, yes, that remains the case. While it’s the minority now, there are still some health care organizations that don’t have transparent environments where people feel safe reporting mistakes. Ideally, we should have 100 percent adoption of a transparent culture where retribution doesn’t factor in. We still have work to do in this area.
Kevin Pho: In your article, you touched on the nursing shortage and nurse burnout. How do these issues intersect with technological approaches to solving them?
Ann-Louise Puopolo: Here’s the thing. We’ve long had technology in the workflow. You know that as a physician, and I know that as a nurse. But sometimes technology isn’t our friend. For example, many of us who practiced years ago dealt with alarm fatigue—there were too many buzzers and whistles alerting us to potential problems. What happened? We stopped hearing them, right? The technology that was supposed to help us became a burden.
I believe that technology, when it’s our friend, needs to be positioned in a way that supports the workflow. It should hardwire processes that help us always do the right thing, rather than relying solely on training, education, and muscle memory. Technology should support the workflow but not overwhelm us with alarms and alerts. Instead, it should stop us from proceeding in the wrong direction or prevent errors without just sounding an alarm.
Kevin Pho: Involving more nurses in health care decisions, especially when it comes to implementing new technology, is crucial. What recommendations would you offer to health care leaders to better involve nurses in these decisions?
Ann-Louise Puopolo: There are three domains we see whenever something goes wrong: technology, workflows (standard operating procedures), and human behavior. These three elements are almost always involved when things go wrong—usually two or three of them are at play.
Understanding where the vulnerabilities lie within these three domains when dissecting a safety event can provide valuable insights. It’s rare for the same problem to occur every time; instead, there’s often a combination of issues across these domains.
Ann-Louise Puopolo: So, understanding those vulnerabilities can help provide the insights we need to mitigate those problems in the future. And anyone would be hard-pressed to say it’s always the same issue—it’s typically a combination of those domains, like a tripod of problems when something goes wrong.
Kevin Pho: Of course, we’re also in the age of artificial intelligence (AI). Tell us how AI could be used to help with the technology fatigue you mentioned earlier, as well as improving transparency when it comes to medical errors and enhancing patient safety.
Ann-Louise Puopolo: Like many others, I’m excited about the potential of artificial intelligence. For the most part, I believe AI will be an enormous benefit in delivering patient care. Of course, as with any new technology, there’s always the concern of unintended consequences, but for the majority of what we need to accomplish in providing high-quality patient care, AI is going to play an important role.
Think about AI as a surveillance capability within the medical record that can help guide us in making the right decisions at the right time through decision support—without mandating action, but rather providing real-time, actionable information. Instead of looking at problems in hindsight, AI allows us to act in real-time, which is crucial.
It’s the new frontier, and if used responsibly—with a human oversight element to ensure it’s functioning as intended—it’s going to transform health care delivery.
Kevin Pho: Could you share a scenario where some of your technological innovations address both nurse burnout and the nursing shortage, as well as reducing medical errors and increasing patient safety? Perhaps a case study or story to illustrate these concepts.
Ann-Louise Puopolo: Unfortunately, there are many examples of these issues. One of the most common problems in health care settings is medication errors. There are numerous steps in the medication process, starting with the physician’s order, which then goes through a series of checks and balances within the pharmacy before reaching the nurse for administration.
So, the responsibility often falls on nursing as the last stop before the medication reaches the patient. Nurses can either contribute to errors—if there’s a problem with the order—or they can prevent harm. Medication errors involve multiple health care professionals and numerous opportunities for something to go wrong—wrong patient, wrong drug, wrong dose, wrong directions.
When safety events related to medication errors are reported into a system, the key is to analyze the causal and contributing factors. Looking at these reports one by one isn’t enough; you need to analyze them in aggregate. Are there patterns in the drugs involved? Is there a particular time of day or day of the week when errors are more likely? Are the providers properly educated? Are there technical failures with barcoding or automated dispensing systems?
By identifying these patterns, we can figure out where improvements are needed to reduce errors and prevent harm. AI plays a huge role here in recognizing patterns and helping us prioritize what to fix first so that these errors become non-events—meaning they don’t happen again.
Kevin Pho: That’s a great example. We’re talking to Ann-Louise Puopolo, a nurse executive. Today’s KevinMD article is titled “Adopting Technology to Support a Nurse Workforce and Provide Smarter, Safer Care Delivery.” Ann-Louise, let’s wrap up with some take-home messages for the KevinMD audience.
Ann-Louise Puopolo: Thank you, Kevin. The most important message I want to leave the audience with is that nurses deserve a seat at the table. They are trusted and respected members of the health care team, and it’s crucial to involve them in decision-making at the leadership level. Let them work with the entire leadership team to be part of the solution.
I’d also like to emphasize that doing the right thing is always necessary, and fostering a culture of safety is paramount. We need to be open to identifying and addressing vulnerabilities in our workflows and standard operating procedures. When someone catches a problem early, we should celebrate that as part of a “good catch” program, rather than focusing on punitive measures.
Kevin Pho: Ann-Louise, thank you so much for sharing your perspective and insights. Thanks again for being on the show.
Ann-Louise Puopolo: Thank you for having me, Kevin.
