Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.

Ashish K. Jha; Julia Laguette; Andrew C. Seger; David W. Bates

Study

Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.

September 17, 2008

Jha AK, Laguette J, Seger AC, et al. J Am Med Inform Assoc. 2008;15(5):647-53.

View more articles from the same authors.

This study examined the utility of a surveillance system that monitors laboratory and pharmacy data in hospitalized patients, and discovered that the system was effective in identifying adverse drug events. Furthermore, investigators implemented a process for an individual reviewer to act on these identified events, potentially reducing their incidence.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals.

September 30, 2009

Getting moving on patient safety—harnessing electronic data for safer care.

November 23, 2011

Restoring trust in VA health care.

June 11, 2014

Public reporting of surgical outcomes: surgeons, hospitals, or both?

October 18, 2017

The global burden of unsafe medical care: analytic modelling of observational studies.

October 2, 2013

Toward a safer health care system: the critical need to improve measurement.

April 27, 2016

Did hospital engagement networks actually improve care?

September 3, 2014

Are Patient Safety Indicators related to widely used measures of hospital quality?

July 9, 2008

Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies.

February 2, 2011

Impact of implementing alerts about medication black-box warnings in electronic health records.

January 19, 2011

Tiering drug–drug interaction alerts by severity increases compliance rates.

January 7, 2009

Hospital governance and the quality of care.

November 18, 2009

Ambulatory computerized prescribing and preventable adverse drug events.

June 8, 2016

Adherence to black box warnings for prescription medications in outpatients.

February 22, 2006

Global priorities for patient safety research.

June 3, 2009

Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.

November 9, 2005

Improving acceptance of computerized prescribing alerts in ambulatory care.

November 9, 2005

Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes.

May 4, 2016

Outpatient adverse drug events identified by screening electronic health records.

June 9, 2010

Outpatient prescribing errors and the impact of computerized prescribing.

August 31, 2005

Reducing diagnostic errors—why now?

September 30, 2015

A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.

July 23, 2008

Adverse drug events in ambulatory care.

March 6, 2005

The vulnerabilities of computerized physician order entry systems: a qualitative study.

December 9, 2015

Rating recommendations for consumers about patient safety: sense, common sense, or nonsense?

April 8, 2009

Evaluation of perioperative medication errors and adverse drug events.

November 4, 2015

How do black-serving hospitals perform on patient safety indicators?: Implications for national public reporting and pay-for-performance.

December 1, 2010

Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.

January 7, 2009

Electronic health record adoption by children's hospitals in the United States.

December 15, 2010

Compensation of chief executive officers at nonprofit US hospitals.

October 30, 2013

Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.

August 19, 2015

Health information exchange and patient safety.

November 7, 2007

Are we heeding the warning signs? Examining providers' overrides of computerized drug–drug interaction alerts in primary care.

January 22, 2014

Does the Leapfrog program help identify high-quality hospitals?

August 6, 2008

Return on investment for a computerized physician order entry system.

March 15, 2006

The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.

August 1, 2018

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts.

February 17, 2021

High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events.

May 20, 2020

Improving medication-related clinical decision support.

March 7, 2018

Ambulatory prescribing errors among community-based providers in two states.

December 21, 2011

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Office-based physicians are responding to incentives and assistance by adopting and using electronic health records.

July 24, 2013

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

The effect of provider characteristics on the responses to medication-related decision support alerts.

July 15, 2015

The costs of adverse drug events in community hospitals.

March 7, 2012

Reduced effectiveness of interruptive drug–drug interaction alerts after conversion to a commercial electronic health record.

May 30, 2018

Association between patient outcomes and accreditation in US hospitals: observational study.

October 31, 2018

The use of computers for clinical care: a case series of advanced US sites.

March 6, 2005

National trends in the safety performance of electronic health record systems from 2009 to 2018.

June 17, 2020

Use of electronic health records in US hospitals.

April 8, 2009

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

April 13, 2011

Clinical reasoning in the context of active decision support during medication prescribing.

April 5, 2017

"I wish I had seen this test result earlier!": dissatisfaction with test result management systems in primary care.

April 3, 2005

National hospital ratings systems share few common scores and may generate confusion instead of clarity.

March 11, 2015

Unexpected hypoglycemia in a critically ill patient.

March 15, 2006

Computerized physician order entry and medication errors: finding a balance.

July 6, 2005

John M. Eisenberg Patient Safety Awards. Research: David W. Bates, MD, MSc, Brigham and Women's Hospital.

March 6, 2005

Digital health and patient safety.

April 27, 2016

Overrides of medication-related clinical decision support alerts in outpatients.

January 8, 2014

Inpatient EHR user experience and hospital EHR safety performance.

October 4, 2023

Benefits and risks of using smart pumps to reduce medication error rates: a systematic review.

October 22, 2014

Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in 2012.

July 24, 2013

Patient safety research: an overview of the global evidence.

March 17, 2010

The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned.

March 17, 2021

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

August 31, 2016

Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Effect of nonpayment for preventable infections in U.S. hospitals.

October 24, 2012

Electronic health records in ambulatory care- a national survey of physicians.

June 25, 2008

Medication reconciliation in ambulatory oncology.

December 5, 2007

Can electronic clinical documentation help prevent diagnostic errors?

March 31, 2010

Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.

November 7, 2018

Medication administration errors by nurses: adherence to guidelines.

January 30, 2013

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

June 15, 2011

Evaluation and certification of computerized physician order entry systems.

November 22, 2006

Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review.

November 22, 2017

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

November 25, 2009

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

How safe are outpatient electronic health records? An evaluation of medication-related decision support using the Ambulatory Electronic Health Record Evaluation Tool.

January 17, 2024

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

Association of hospital public quality reporting with electronic health record medication safety performance.

October 6, 2021

Improving safety with information technology.

March 6, 2005

Health apps and health policy: what is needed?

October 24, 2018

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

May 4, 2011

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

September 21, 2016

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

May 10, 2017

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

February 28, 2018

Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools.

February 8, 2012

Preventable adverse drug events and their causes and contributing factors: the analysis of register data.

February 16, 2011

Incidence of adverse drug events and medication errors in Japan: the JADE Study.

November 3, 2010

Adverse events and near misses relating to information management in a hospital.

June 22, 2016

Racism and electronic health records (EHRs): perspectives for research and practice.

April 12, 2023

Pediatric medication safety and the media: what does the public see?

June 21, 2006

The incidence and severity of adverse events affecting patients after discharge from the hospital.

March 6, 2005

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

April 6, 2016

Medication discrepancies in resident sign-outs and their potential to harm.

December 5, 2007

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

February 3, 2016

Improving electronic health record usability and safety requires transparency.

December 12, 2018

Physician burnout in the electronic health record era: are we ignoring the real cause?

May 9, 2018

What practices will most improve safety? Evidence-based medicine meets patient safety.

April 12, 2006

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

July 18, 2007

Related Resources

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Journal Article

Study

Reducing hospital harm: establishing a command centre to foster situational awareness.

March 29, 2023

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Improving the specificity of drug-drug interaction alerts: can it be done?

April 6, 2022

Detection of medication-related problems in hospital practice: a review.

October 2, 2013

Risk factors for hospital admissions associated with adverse drug events.

August 28, 2013

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

May 15, 2013

Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events.

October 24, 2012

Nurse–pharmacist collaboration on medication reconciliation prevents potential harm.

August 22, 2012

Concept and development of a discharge alert filter for abnormal laboratory values coupled with computerized provider order entry: a tool for quality improvement and hospital risk management.

June 13, 2012

An adverse event screening tool based on routinely collected hospital-acquired diagnoses.

May 30, 2012

Automated identification of extreme-risk events in clinical incident reports.

February 8, 2012

Creating a web-based incident analysis and communication system.

November 2, 2011

Electronic health record-based surveillance of diagnostic errors in primary care.

November 2, 2011

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.

October 19, 2011

Medicines reconciliation using a shared electronic health care record.

September 14, 2011

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

September 14, 2011

Developing a programme for medication reconciliation at the time of admission into hospital.

September 7, 2011

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

August 24, 2011

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

August 24, 2011

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

July 27, 2011

Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms.

July 20, 2011

Scanner beep only means the barcode has been scanned.

July 13, 2011

Potential safety gaps in order entry and automated drug alerts: a nationwide survey of VA physician self-reported practices with computerized order entry.

June 22, 2011

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

June 8, 2011

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

June 8, 2011

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

May 25, 2011

See More About The Topic

General Hospitals

Quality and Safety Professionals

Information Professionals

General Internal Medicine

Hospital Medicine

Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Reducing hospital harm: establishing a command centre to foster situational awareness.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Reducing hospital harm: establishing a command centre to foster situational awareness.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site