Root Cause Analysis of Repetitive Strain Injuries Sustained by Heart and Circulation Pharmacists

Issue
In the fall of 2006, 40% of Heart and Circulation pharmacists at the Toronto General site of the University Health Network (UHN) were on modified work leave from repetitive strain injuries. The injuries involve the wrist and forearm with symptoms consistent with inflammation of the carpel tunnel called carpel tunnel syndrome (CTS). This number of concurrent injuries has never occurred in this worker population at UHN. The problem arose on the heels of the implementation of an electronic medication order entry system that has changed the nature of the tasks and workload for pharmacists.

Methods
In addition to a physical ergonomic assessment by the Rehab Solutions team at UHN, the Healthcare Human Factors Group conducted an investigation of the tasks, workflow, physical work environment, schedule and culture of the Heart and Circulation Pharmacy team. Field study (direct observation) was the primary method for collecting data. Additionally, Morae screen capture software was used to record pharmacy order processing and analyze the time, mouse clicks, and key stokes required to complete problematic or unnecessary tasks.

Results
The data collected suggests that the primary contributing factor to the RSIs experienced by Heart and Circulation pharmacists is their workload associated with mouse and keyboard tasks. The introduction of MOE/MAR has increased the amount of time and computer input device use (i.e., mouse and keyboard) due to a variety of factors, primarily poor user interface design and poor system integration between MOE/MAR and the pharmacy information system. 22 recommendations to address each of the contributing factors have been made, and the relevant hospital department and/or committee are being notified of how they can contribute towards improvements that will reduce unnecessary workload and improve patient safety.

Additional Learnings
This project helped to illustrate the importance of prospectively evaluating the impact of implementing new information technology on the workflow and workload of users. A detailed workflow analysis of current practices to identify changes that will occur when moving to the new system and high fidelity usability testing to identify unanticipated issues caused by poor user interface design is required.