Technology in Nursing: Health Disparities in Tanzania Impact Patient Safety
Elizabeth Diehl, Cedar Crest College
Abstract: Technology in nursing is constantly evolving to improve patient safety. Various technologies such as electronic medical records, electronic physician orders, barcoding, automated medication dispensing cabinets, and retained surgical items detectors have been shown to increase patient safety in developed countries through the reduction of errors; however, there is still room for improvement. New and emerging technologies such as smart pumps, smart beds, video monitoring, wearable electronic devices, artificial intelligence, and robotics seek to further prevent unnecessary harm to the patient. Although these technologies are widely accessible here in the United States, third world countries such as Tanzania do not have equal access to such costly technologies, and this major health disparity can negatively impact patient safety.
Keywords: technology, nursing, patient safety, health disparities, Tanzania
Patient safety has become an increasing priority in the nursing profession and is defined as “the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of health care” (Alotaibi & Federico, 2017). The use of various technologies in the healthcare system has greatly improved patient safety through better communication, documentation, access to patient records, reducing medication administration errors, and increasing safety in the operating room (Alotaibi & Federico, 2017). As more healthcare facilities and professionals have been paying greater attention to technology’s effects on patient outcomes, it is evident that although current technologies have increased patient safety, further improvement is warranted. There are new emerging technologies including smart beds, smart pumps, video monitoring, wearable devices, artificial intelligence, and robotics, and while these are designed to further increase patient safety, the hefty cost of these technologies needs to be considered when implementing them into healthcare settings. This is especially important when considering equal access on a global level.
Third world countries such as Tanzania struggle with the economic costs, access to education, access to quality healthcare, and environmental factors necessary to access and utilize technologies in the healthcare field. These factors all work together to make up social determinants of health, or the conditions of a person’s environment that affect their health, functioning, and quality of life (“Social Determinants of Health,” n.d.). People in Tanzania do not have access to the education and quality healthcare people in the Unites States have due to the poor economic stability and environmental conditions faced in the country. The healthcare facilities and people in Tanzania are unable to access and afford the following technologies, thus all the benefits to patient safety that come along with each technology is also inaccessible. This leaves people in Tanzania unable to gain the benefits in patient safety, leaving more room for errors and detrimental outcomes such as patient injury or death.
History of Technologies in Nursing & Current Practice
Clinical Communication and Collaboration Platforms
Clinical communication and collaboration platforms play a key role in establishing workflow efficiency. Although many healthcare facilities in developed countries have bedside computers, clinical communication and collaboration platforms add a new level of mobility, allowing nurses to carry a computer, phone, and camera all in one, and thus have access to patient records and interdisciplinary communication at any given moment (Machon et al., 2020).
Electronic Medical Records
An electronic medical record assists nurses and other healthcare professionals with accessing patient information and updating the patient status (What is an electronic health record (EHR)?, 2019). It is also a way to create and keep track of plans of care and any interventions or treatments a patient is receiving. Having a handheld device such as a smartphone with access to the electronic medical record allows nurses to document and access patient information in real-time (What is an electronic health record (EHR)?, 2019). It also has a camera that can function as a barcode scanner to scan the patient’s identification band and medication barcodes for documenting their administration. In addition to scanning barcodes, the camera can also be used for taking images of a patient’s wounds to document. This allows nurses to document at the patient’s bedside, reducing documenting errors later and increasing patient safety by maintaining up-to-date documents for clinicians to keep track of changes in patient status.
Electronic Physician’s Orders
Electronic physician’s orders are designed for the purpose of improving patient safety by decreasing medication order errors. This system allows physicians to order medications electronically via the electronic medication administration record and eliminates the possibility of errors occurring, as they may, when the order is provided verbally or via telephone, making it difficult to understand or be heard clearly resulting in incorrect medication, dose, route, time, or patient. A quasiexperimental, pretest-post-test study conducted by Devine et al. (2010) in a multispecialty health system compared written prescriptions to the use of electronic physician’s orders and found the frequency of errors declined by 70%. The areas of biggest improvement were seen in legibility of orders when moving from hand-written to computer entry, correct abbreviations, and inclusion of all pertinent information, ensuring patients are receiving the correct medications. In addition to medication orders, electronic physician’s orders have continued to evolve to also include electronic ordering of tests, procedures, and consults. This not only allows for fewer errors, but also increased efficiency that subsequently improves the timing and quality of patient care (Alotaibi & Federico, 2017).
Clinical Decision Support
The integration of clinical decision support into electronic physician’s orders has been shown to significantly decrease medication errors, as it prompts prescribers to intervene and prescribe based on clinical guideline recommendation (Alotaibi & Federico, 2017). It alerts the prescribers to any patient allergies and drug interactions based on information already entered in the electronic medical record. It also makes prescription suggestions to providers in real time based on those identified allergies, as well as flags out-of-range dosages or risky drug interactions (Bates & Singh, 2018). This adds an extra level of safety for the patient by double checking the prescriber’s orders and prescriptions.
It is imperative that prescribers acknowledge and follow these recommendations for clinical decision support to be effective, which is not always the case. A study conducted by Shah et al. (2006) looked at thirty-one adult primary care practices based in the Boston area and their use of computerized prescribing and use of clinical decision support systems. The study found that 33% of clinical decision support alerts were overridden by physicians, 14% of these with no reason. This means that when a physician was given an alert of a possible allergy, drug-to-drug interaction, or other contraindication for the medication being prescribed, they chose a reason to give it anyway. Of those who ignored it, they chose the option of other but then did not provide reasoning as to why. This extra level of technology is intended to double-check the physician’s orders and increase the likelihood that nurses are receiving accurate and safe orders for their patients, thus decreasing the risk of any adverse event, error, or safety concern for the patient. However, it is up to the physician to appropriately acknowledge and reconsider these alerts when entering their orders to assure the appropriate intentions of patient safety are present when utilizing clinical decision support systems.
Automated Medication Dispensing Cabinets
Automated medication dispensing cabinets also contribute to efficiency, quality of care, and most importantly patient safety. These dispensing cabinets are electronic cabinets that store medication in an organized way to keep track of stock and distribution while allowing controlled dispensing of prescriptions at the point of care (Alotaibi & Federico, 2017). Automated medication dispensing cabinets help keep track of medication inventories on each unit. This allows the pharmacy to stock medications that are commonly used on that specific unit, providing easy access for nurses, and ensuring they can give patients their medications at the exact time it is due instead of having to wait and request medications from the pharmacy. This results in a more efficient and better-quality healthcare system, as well as improved patient safety (Chapuis et al., 2010). It is important for certain medications such as antihypertensives and antidiabetics to be given at the correct time to prevent any adverse events such as an extremely high blood pressure reading leading to a risk of seizures or a hyperglycemic event. Ensuring medications are given at the correct time reduces the risk of the patient’s condition becoming unstable.
To further enhance patient safety, automated medication dispensing cabinets connect to the electronic medication administration record within the electronic medical record to keep track of prescribed medications and due times for each medication on the unit. This connection between these technologies only allows nurses to have access to that specific medication they choose to withdraw and give, while also instructing the nurse on the dosage based on the orders in the electronic medication administration record. Chapuis et al. (2010) conducted a study in intensive care units in which they introduced an automated dispensing cabinet in one and compared it to another unit as a control. They observed the unit function before and after and found that the implementation of automated medication dispensing cabinets reduced the rate of medication errors by 28%.
Barcoding Medication Administration
Barcoding medication administration is the scanning of barcode labels on both the patient identification band and medications to prevent medication error, thus enhancing patient safety. This process ensures the five rights of medication administration (the right patient is receiving the right dose of the right medication via the right route, at the right time) and reduces medication errors by 57% (Khammarnia et al., 2015). Poon et al. (2010) conducted a before-and-after quasiexperimental study in thirty-five adult medical, surgical, and intensive units. They compared error rates in units that implemented bar-coding in comparison to those that had not and found that the implementation of barcoding medication administration decreased wrong medication errors by 57.4%, wrong dose errors by 41.9%, and wrong route of administration errors by 68%. It also assists with documentation of the medication administration via direct communication with the electronic medical record and documenting the barcoding directly into the electronic medication administration record. By communicating with the electronic medication administration record, it also alerts the nurse giving the medication to any incorrect information or contraindication to prevent adverse effects and patient harm. A systematic review study found that this integration of barcoding with the electronic medication administration record reduced medication administration errors by 50-80% (Alotaibi & Federico, 2017). However, the implementation for barcode medication administration was found to increase distractions or interruptions by 9.7%, along with medications being given without explanation to the patient (Shah et al., 2016).
Retained Surgical Items Detector
Retained surgical items detector includes various technologies that are now being used to add a second layer of protection from retained surgical items. They typically include bar coding and radiofrequency tagging of surgical items (Alotaibi & Federico, 2017). All surgical tools are barcoded or chipped with a certain device that can be detected via x-ray. An x-ray is taken before the final closing of a surgical incision in the operating room to prevent retained surgical items. This is vital to patient safety in surgeries, as retained surgical items can lead to serious complications and infection after surgery. It is important to note that some older supplies may not be tagged, so it is still pertinent to perform surgical instrument counts to ensure everything is accounted for (Alotaibi & Federico, 2017).
All these technologies are currently in use in most hospitals throughout the United States as an effort to improve patient safety. However, there is still room for improvement, and as technology continues to advance, more opportunities arise to enhance and improve these already existing technologies.
New & Future Technologies in Nursing Practice
Some of the newest technologies becoming known in the nursing profession include smart pumps, smart beds, video monitoring, wearable devices for remote monitoring, the use of artificial intelligence, and robotics. All these technologies have been created and are being implemented as an attempt to continue the improvement of patient safety both in and out of the healthcare setting.
Smart Pumps
As discussed previously, technologies such as automated medication dispensing cabinets, electronic medication administration records, and barcoding medication administration have been implemented in the nursing profession and have shown to greatly enhance patient safety. Nonetheless, even with these technologies in place, medication administration errors are still too common. The main medication administration route that these technologies fail to cover includes intravenous (IV). Intravenous medication administration includes the administration of a medication directly into the bloodstream via a catheter placed into a vein. Most often, this requires a pump that allows the nurse to program the type of medication, dose, and rate of administration. With the nurse having to manually program the pump with this information, there is still a considerable risk for error that a nurse may input the incorrect information. To solve this problem, smart pumps have been introduced into the nursing profession.
Smart pumps allow the nurse to utilize barcode scanning to scan the pump after scanning the patient and medication (Rothschild et al., 2005). This connects the pump to the electronic medication administration record utilizing a wireless connection. This communication between the pump and electronic record automatically programs the pump to the order for that specific medication ordered in the record. This removes the step where nurses manually enter in this information, eliminating an opportunity for errors. However, this is dependent upon accurate physician entry of the order into the electronic medication administration record, as well as the nurse to scan the pump. Rothschild et al. (2005) conducted a prospective randomized time-series trial comparing serious medication error rate between the use of smart pumps and a control group. The results of this study revealed that smart pumps could detect medication errors and adverse drug events, but only if smart pumps are scanned and utilized correctly, as nurses were bypassing the drug library 25% of the time. This is also only limited to IV medications that are being infused over the pump. This still leaves IV push medication, that nurses push through the IV by hand without the use of a pump, open to medication errors.
Smart Beds
Smart beds are a recent technology in which hospital beds are equipped with sensors and new features to monitor patients and enhance patient safety. The basic sensors and capabilities of smart beds include monitoring patient vital signs such as heart rate and respiratory rate and rotating and turning patients who are unable to do so themselves (Tak et al., 2023). The ability for a bed to obtain vital signs limits the need for a pulse oximeter cord, thus decreasing risks for falls and skin breakdown from either the pulse oximeter sticker itself or the cord if pressed up against the patient’s skin for too long. The weighing feature of the smart bed also decreases the risk of patient falls, as it eliminates the need for patients to get up out of bed to stand on a scale to be weighed (Tak et al., 2023). It can also be beneficial for medication administration when the medication is weight-based, and the dose is dependent on how much the patient weighs. Additionally, monitoring weight is important for patients who have heart failure or problems with their kidneys, as it is an easier way for nurses to monitor their weights more frequently to ensure they are not retaining fluid.
The rotating feature of the smart bed also greatly improves patient safety by turning and rotating patients who are unable to do so themselves to prevent pressure injuries and skin breakdown. Not only does this improve patient safety, but it also improves nurse safety by saving nurses from having to strain themselves trying to roll or turn patients. These smart beds can be set to time intervals to ensure patients are turned every two hours as evidence-based practice recommends, or at different intervals based on patient needs. However, as mentioned previously, smart beds, just like every technology, come with the possibility of causing patient harm rather than improving patient safety. In a cross-sectional survey done by Tak et al. (2023), 349 nurses were questioned on their perceptions of the smart bed. Although the overall response was acceptance of the smart bed, the nurses also reported fear of the rotating feature of smart beds getting caught on necessary tubes and equipment attached to patients and sometimes dislodging these devices.
Video Monitoring
Video monitoring has become a prevalent technology used in the healthcare setting since the COVID-19 pandemic. Video monitoring allows a nurse to continuously monitor several patients via a two-way camera with two-way audio in place of a person face-to-face in the room. This allows for the monitoring of patients who have a high fall risk or are just being monitored more closely. This video monitoring is restricted to in-patient monitoring, or those patients who are in a healthcare facility or hospital. New and emerging technology, known as smart homes, takes this technology one step further and allows monitoring of patients within their own homes.
Smart homes utilize several types of technology to monitor patients from the comfort of their own homes. A patient’s home is equipped with internet devices and sensors in every room, except the bathroom to maintain privacy (Facchinetti et al., 2023). These devices and sensors can track a patient’s movement and detect where the patient is, when they move, and for how long. This allows clinicians to keep track of a patient’s mobility, when they are most active, their bathroom habits, and if they have fallen. This can improve patient safety by increasing the accuracy of data provided to clinicians regarding these habits, as well as prevent safety concerns regarding patient falls at home and long down times leading to further health complications.
Devices can be paired with these sensors to also control lighting and temperature in homes creating a safer environment for patients. In addition to improving safety and security, alarms can also be set and paired with sensors to monitor a patient’s medication routine. This can remind patients when to take their medications so that they are more compliant with taking their medications at the prescribed time. Smart homes also allow for monitoring of patients with chronic diseases to stay in the comfort of their own home while being monitored.
Wearable Electronic Devices
Not only does technology facilitate communication between people, but it also allows the machines to communicate with the nurses. An example of this is the use of telemetry and cardiac monitors, which are wirelessly connected to these smart devices, continuously sending data to the electronic medical record. The electronic medical record can have push notifications set up to alarm the nurse of any abnormal reading on these monitors. Parameters on the cardiac monitors can be set for normal limits of a patient’s vital signs and cardiac rhythm. When the monitor picks up something outside of these parameters, an alert can be sent to the mobile device, immediately notifying a nurse. This allows the nurse to see what is going on with the patient in real-time whether they are at a computer or not and respond quickly. The settings can also allow what is known as intelligent alarms or alert escalation (Machon et al., 2020). This setting ensures the nurse is aware of the abnormal data if they get distracted or busy by reminding them with multiple alarms if they did not respond to subsequent ones. In addition to cardiac alarms, alarms can also include patient call bells or bed alarms that send notifications when activated.
Although remote patient monitoring was utilized prior to the COVID-19 pandemic, it has become more prevalent post-pandemic. Remote patient monitoring allows clinicians to monitor their patients in near-real time either while they are in their own homes or simply in different areas of the hospital. The most common type of remote monitoring is pulse oximetry, but blood pressure, electrocardiogram, heart rate, and temperature can also be monitored remotely. This allows those who only have mild symptoms or are at a decreased risk of developing complications to stay in the comfort of their own home and decrease the workload of nurses and other clinicians, as well as hospital capacity in general. Padula et al. (2022) found that remote monitoring can decrease hospitalizations by 87% and reduce deaths by 77%. This also enhances patient safety because not only are they being monitored to ensure they are in optimal health, but physicians or nurses who are monitoring them remotely can call the patient and advise them if they need to seek medical attention at any point. By allowing patients to remain at home, it also decreases their exposure to other sick people in the healthcare setting and decreases their risk of acquiring a hospital-acquired disease or infection.
Artificial Intelligence
ChatGPT is a form of artificial intelligence in which technology and software are used to provide answers, explanations, and human-like responses to almost any question or input (Chow et al., 2023). ChatGPT can be utilized in the nursing profession to create discharge summaries and increase patient safety after discharge. Discharge summaries are a set of instructions, new medications, upcoming appointments, and contact information for the patient to refer to after leaving the hospital or other clinical setting. Discharge summaries can be extensive and time consuming to create, as they are individualized for each individual patient. However, having ChatGPT create them could save a lot of time for clinicians and ensure nothing is left out and no mistakes are made either with spelling or forgetting information. Ensuring patients have all the information and instructions once they get home decreases the risk of re-admission and frequent, unnecessary phone calls and doctor visits (Chow et al., 2023).
In addition to creating discharge summaries, ChatGPT can simply be used to retrieve medical information. Both patients and clinicians can ask ChatGPT questions regarding symptoms, medications, medical diagnoses, etc. ChatGPT can then be programmed with medical information to answer any questions. This is more specifically known as a medical chatbot, as it includes medical knowledge (Chow et al., 2023). This could be a great tool if programmed correctly by medical professionals, as it could allow patients and clinicians to get faster and more reliable answers than searching on the internet.
Robotics
Artificial Intelligence can go beyond ChatGPT to extend even further to the world of robotics. Robotics utilized in healthcare and nursing are termed care robots (Stokes & Palmer, 2020). The future of care robots looks at their implementation into the nursing profession to relieve the nursing shortage. The idea of care robots is that it can essentially perform the job of a nurse by taking care of patients, administering medications, performing procedures, and educating patients. The goal is that care robots will have a lower risk of error and harming a patient than a human nurse. This could be due to robots being programmed and only following this programming and the data it is given. Therefore, it eliminates the possibility of thinking on its own and making the wrong decision. However, this brings about a debate as to whether care robots should be utilized in nursing and to what extent. Some believe care robots should only be utilized for tasks such as fetching and retrieving products and should therefore work alongside a nurse rather than in place of one (Stokes & Palmer, 2020). This would eliminate any errors that could arise from malfunction or breaking of the robot. The question as to whether care robots can fulfill the important caring aspect of nursing also remains. Although care robots can be programmed to use therapeutic communication, there is still something about the human touch and human’s ability to sympathize and empathize with a patient that robots just are not able to achieve. This leaves the use of care robots in the nursing profession at a standstill.
Technology’s Impact on Social Determinants
Technological advancements in the nursing profession have been shown to improve patient safety. This is evident in each technology discussed in this paper, but technology comes with a price. Technology itself is expensive, which means healthcare facilities implementing these technologies must be able to afford it. Additionally, these facilities may then bill for these technologies, thus making it more expensive for the patient or their insurance. If a patient’s insurance does cover the expense, patients may see an increase in insurance prices to be able to compensate for this increase in price. Introducing modern technologies also requires hiring staff who can repair, update, and manage these technologies, which adds another expense to facilities. It requires that nurses and other clinicians utilizing these devices be educated on how to use them. Although this is not always a problem seen here in the United States, rural facilities and underdeveloped countries with less funds have a disadvantage when it comes to the ability to afford technologies. This becomes a problem because if facilities are not able to afford the technologies, they will not be able to reap the benefits of improved patient safety that comes along with these technologies.
Personal Reflection on a Recent Trip to Tanzania
I recently took a trip to Tanzania in January 2024, with my school to set up clinics and provide care to people in rural villages. We traveled about an hour one-way to two different villages, handed out appointment cards, and then returned the following day to set up a clinic and provide care and medications to those in need. We also took donations of toiletries, shoes, and clothes to hand out to these people, as they did not have access or the financial means to afford some of these things. As we visited their homes, we also noticed most people did not have running water, electricity, or proper housing, putting them at increased risk of developing medical complications. Each of these villages does have a clinic for people to seek health care for minor illnesses, but they must pay to see a doctor and receive treatment. After talking to the people in these villages, most do not have the financial means to even seek out care at their local clinic, nor do these people have health insurance, as most are farmers who live off their land. There are not a lot of big corporate jobs and warehouses as seen in the United States leaving those in Tanzania lacking health insurance and ability to afford care. This leaves those in need of medical attention unable to afford a hospital or doctor visit, resulting in the delay or lack of treatment and sometimes even premature death. In addition to the financial hardships, transportation in Tanzania is limited. Again, most people are unable to afford cars, bikes, bus fares, and other means of transportation. For this reason, many are left having to walk; however, most hospitals and clinics are hours away from rural areas resulting in an additional barrier to people seeking care.
I also had the opportunity to visit the local Kibosho Hospital, which was about an hour by car from where we were staying. The next closest hospital was several hours away by car. If a person were to be seeking medical treatment from a hospital, they most likely are ill and would not be able to endure hours of walking to get there if unable to afford transportation. This leaves the people of Tanzania not able to seek out proper medical care when necessary. However, despite the lack of access and ability to afford healthcare, people in Tanzania have hope for better access and more advanced health care as service groups like ours continue to help.
For those in Tanzania who can access a hospital or health facility and can afford services, the lack of access to technology and resources greatly impacts their patient safety. Particularly looking at Kibosho Hospital in northern Tanzania, in the past two to three years hospitals have moved patient files from paper to electronic records, along with digitalizing the single x-ray machine in the hospital. However, clinics in smaller, more rural communities still utilize paper medical records. This move towards electronic medical records has improved communication between clinicians along with reduced misdiagnoses and medical errors (Mwogosi et al., 2023). In addition, Tanzania hospitals do have access to artificial intelligence to predict outbreaks of cholera and malaria (Sukums et al., 2023). This is beneficial for early prevention to prevent serious complications and premature death, as it allows nurses and clinicians to intervene and provide treatment for a patient before it is too late.
Most of these current technological advancements in Tanzania remain within urban areas, so rural areas still lack access. This was observed in Kibosho Hospital in which there is no computed tomography machine, no barcoding for medication administration, and no electronic medication administration dispensing cabinets. Medications are kept in a wooden cabinet with glass doors in patient rooms. All these things can lead to inability to diagnose, proper patient and medication identification, and an overall higher risk in errors and harm to the patient. I was also able to see this firsthand, as the doctor working with us at the clinics diagnosed and prescribed medications for people based solely on their symptoms. There was no equipment or technology to run tests, scans, or other procedures to confirm a diagnosis. As the assigned pharmacist at the first clinic, I also witnessed their handling of medications. With little resources, we had very limited supply of medications. As I received written orders from the doctor, I had to decipher his handwriting to be able to get the correct medication and count out the correct dose. Most of these patients would receive only partial doses, as there was not enough for everyone. We also ended up substituting some medications as we ran out, which may not have had the same benefit or effect for the patient. All these factors pose higher risks for the patient’s safety that could be decreased with the integration and use of technology.
Conclusion
The future of technology not only relies on the nurse’s ability and willingness to utilize it in practice, but also providing equal access to people living in rural and underdeveloped areas. This means not only ensuring healthcare facilities have access to all technologies necessary to improve patient safety but ensuring the people in that area can afford the care. Places such as Tanzania and rural communities deserve equal access to all technologies deemed to improve patient safety, but the methods to increase access is questionable. Perhaps there is a way for government agencies to fund these necessary technologies to facilities and areas who cannot afford it and provide more affordable technology. Or maybe the focus needs to be on efforts to provide everyone with access to affordable insurance and healthcare to be able to afford treatment in the first place.
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