AHRQ Patient Safety Network

The Collection > Clinical Information Systems

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Safety Target

•Device-related Complications (10)

•Diagnostic Errors (28)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (90)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (370)

•Medical Complications (25)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (14)

•Transfusion Complications (4)

•Psychological and Social Complications (5)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (16)

Resource Types

•Clinical Guideline (1)

•Journal Article (503)

•Legislation/Regulation (7)

•Meeting/Conference (3)

•Newspaper/Magazine Article (86)

•Special or Theme Issue (4)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (146)

•Active Errors (112)

•Latent Errors (47)

•Near Miss (3)

Approach to Improving Safety
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Clinical Information Systems

•Computerized Provider Order Entry (CPOE) (291)

•Computerized Decision Support (129)

•Electronic Health Records (177)

Clinical Areas

•Allied Health Services (2)

•Medicine (388)

•Nursing (35)

•Pharmacy (164)

Target Audience

•Health Care Providers (411)

•Health Care Executives and Administrators (490)

•Non-Health Care Professionals (453)

•Patients (33)

Setting of Care

•Hospitals (375)

•Psychiatric Facilities (1)

•Residential Facilities (7)

•Ambulatory Care (104)

•Outpatient Surgery (3)

1 - 20 of 631

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STUDY

Evaluation of a physician informatics tool to improve patient handoffs.

Flanagan ME, Patterson ES, Frankel RM, Doebbeling BN. J Am Med Inform Assoc. 2009;16:509-515.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

STUDY

Physicians-in-training attitudes on patient safety: 2003 to 2008.

Sorokin R, Riggio JM, Moleski S, Sullivan J. J Patient Saf. 2011;7:132-137.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

STUDY

Multi-professional patterns and methods of communication during patient handoffs.

Benham-Hutchins MM, Effken JA. Int J Med Inform. 2010;79:252-267.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

NEWSPAPER/MAGAZINE ARTICLE

As industry automates, adverse events continue to haunt caregivers.

Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.

STUDY

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. J Am Med Inform Assoc. 2013 Mar 14; [Epub ahead of print].

ORGANIZATIONAL POLICY/GUIDELINES

Safely implementing health information and converging technologies.

Sentinel Event Alert. December 11, 2008;(42):1-4.

COMMENTARY

Mitigating error vulnerability at the transition of care through the use of health IT applications.

Cortelyou-Ward K, Swain A, Yeung T. J Med Syst. 2012;36:3825-3831.

STUDY

Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens.

Göbel B, Zwart D, Hesselink G, Pijnenborg L, Barach P, Kalkman C, Johnson JK. BMJ Qual Saf. 2012;21:i106-i113.

STUDY

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.

Holden RJ. Cogn Tech Work. 2011;13:11-29.

STUDY

Physician reporting of clinically significant events through a computerized patient sign-out system.

Nabors C, Peterson SJ, Aronow WS, et al. J Patient Saf. 2011;7:154-160.

COMMENTARY

Glucose Roller Coaster.

Sharpe BA. AHRQ WebM&M [serial online]. July 2004.

STUDY

Clinical information technologies and inpatient outcomes: a multiple hospital study.

Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Arch Intern Med. 2009;169:108-114.

STUDY

Hospital rules-based system: the next generation of medical informatics for patient safety.

Wilson JW, Oyen LJ, Ou NN, et al. Am J Health Syst Pharm. 2005;62:499-505.

STUDY

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

Leung AA, Keohane C, Lipsitz S, et al. J Am Med Inform Assoc. 2013 Apr 18; [Epub ahead of print].

STUDY

Using computerized provider order entry and clinical decision support to improve referring physicians' implementation of consultants' medical recommendations.

Were MC, Abernathy G, Hui SL, Kempf C, Weiner M. J Am Med Inform Assoc. 2009;16:196-202.

STUDY

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. Int J Med Inform. 2009;78(suppl 1): S69-S76.

NEWSPAPER/MAGAZINE ARTICLE

Checking the right boxes, but failing the patient.

Rifkin D. New York Times. November 16, 2009;Science Desk:5.

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