Higher accuracy of complex medication reconciliation through improved design of electronic tools.

Jan Horsky; Elizabeth A. Drucker; Harley Z. Ramelson

Study

Higher accuracy of complex medication reconciliation through improved design of electronic tools.

January 31, 2018

Horsky J, Drucker EA, Ramelson HZ. J Am Med Inform Assoc. 2018;25(5):465-475.

View more articles from the same authors.

This head-to-head comparison of two different medication reconciliation tools in electronic health records demonstrated that clinicians using one electronic platform made significantly fewer errors compared to clinicians using the other. The authors advocate for conducting this type of rigorous user testing to ensure electronic health record safety.

PubMed citation

Free full text

Related Resources From the Same Author(s)

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

July 21, 2010

Comprehensive analysis of a medication dosing error related to CPOE.

August 31, 2005

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

April 5, 2017

Safety issues in combined gynecologic and plastic surgical procedures.

August 15, 2007

Mapping changes in surgical mortality over 9 years by peer review audit.

July 20, 2005

From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.

March 6, 2005

Will my patient fall?

January 17, 2007

The incidence of adverse events among home care patients.

January 30, 2013

Challenging authority and speaking up in the operating room environment: a narrative synthesis.

February 27, 2019

Under-mined.

January 17, 2007

Application of human error theory in case analysis of wrong procedures.

June 16, 2010

Quality, patient safety, and the cardiac surgical team.

June 19, 2013

Blame: what does it look like?

November 14, 2018

Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes.

August 2, 2017

Recognizing and managing errors of cognitive underspecification.

March 19, 2014

Patient safety and technology.

May 20, 2009

Unreported errors in the intensive care unit: a case study of the way we work.

November 14, 2007

Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.

December 13, 2017

Patient safety informatics: criteria development for assessing the maturity of digital patient safety in hospitals.

June 29, 2022

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

Paramedic self-reported medication errors.

October 18, 2006

Paramedic self-reported medication errors.

January 17, 2007

An investigation of diagnostic accuracy and confidence associated with diagnostic checklists as well as gender biases in relation to mental disorders.

December 21, 2016

The normalization of deviance: a threat to patient safety.

July 20, 2011

Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams.

June 1, 2011

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review.

September 11, 2013

Blind spots in the science of safety.

May 8, 2019

A pediatric medical emergency team manages a complex child with hypoxia and a worried parent.

March 28, 2007

Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.

October 2, 2013

Use of e-triggers to identify diagnostic errors in the paediatric ED.

April 6, 2022

Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly.

May 16, 2007

Using clinical simulation to teach patient safety in an acute/critical care nursing course.

August 3, 2005

Patient safety and quality improvement: an overview of QI.

August 29, 2012

Exploring mediating effects between nursing leadership and patient safety from a person-centred perspective: a literature review.

September 8, 2021

Medication safety: just a label away.

October 24, 2007

Safety-relevant mode confusions—modelling and reducing them.

June 1, 2005

Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency.

December 2, 2015

Journey to no preventable risk: The Baylor Health Care System patient safety experience.

November 3, 2010

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

July 6, 2022

Momentary interruptions can derail the train of thought.

January 30, 2013

Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives.

July 21, 2021

Making care better in the pediatric intensive care unit.

January 30, 2019

Reducing pediatric medication errors: children are especially at risk for medication errors.

May 18, 2005

Implementing a perioperative handoff tool to improve postprocedural patient transfers.

March 7, 2012

Interruptions in emergency department work: an observational and interview study.

May 15, 2013

Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.

March 27, 2013

The relationship between the learning and patient safety climates of clinical departments and residents' patient safety behaviors.

October 17, 2018

The next step in learning from sentinel events in healthcare.

April 15, 2020

Identifying potential patient safety issues from the Federal Electronic Health Record Surveillance Program

January 29, 2020

Fostering transparency in outcomes, quality, safety, and costs.

October 12, 2016

Team training: implications for emergency and critical care pediatrics.

May 28, 2008

Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy.

December 19, 2012

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe.'

June 10, 2009

Systematic workup of transfusion reactions reveals passive co-reporting of handling errors.

November 8, 2023

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

August 17, 2016

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital.

May 13, 2009

Supporting clinicians after adverse events: development of a clinician peer support program.

September 5, 2018

An evaluation of shared mental models and mutual trust on general medical units: implications for collaboration, teamwork, and patient safety.

November 29, 2017

Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility.

May 7, 2008

Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine.

November 25, 2015

Sleep deprivation and starvation in hospitalised patients: how medical care can harm patients.

October 21, 2015

Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds.

June 12, 2013

Surveillance: a strategy for improving patient safety in acute and critical care units.

April 18, 2012

Characterization of adverse events detected in a large health care delivery system using an enhanced Global Trigger Tool over a five-year interval.

April 9, 2014

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

How to avoid catastrophic events on the ward.

July 27, 2016

Exploring varieties of knowledge in safe work practices—an ethnographic study of surgical teams.

October 12, 2011

Errors in the medication process: frequency, type, and potential clinical consequences.

March 6, 2005

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.

January 31, 2018

Emergency physician perceptions of electronic health record usability and safety.

May 12, 2021

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care.

August 5, 2015

Patient Safety Innovations

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

September 29, 2021

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.

September 8, 2021

Nurse decision making in the prearrest period.

January 6, 2010

Pediatric obesity and safety in inpatient settings: a systematic literature review.

May 21, 2014

Antibiotic prescribing errors in patients discharged from the pediatric emergency department.

March 30, 2022

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients.

September 28, 2016

Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention.

September 4, 2013

Learning from incidents in healthcare: the journey, not the arrival, matters.

April 27, 2016

Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 opioid guideline.

September 12, 2018

Bad things can happen: are medical students aware of patient centered care and safety?

January 25, 2023

Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study.

March 24, 2021

How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis.

November 13, 2019

Time to take hearing loss seriously.

February 19, 2020

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

November 15, 2006

Using human factors design principles and industrial engineering methods to improve accuracy and speed of drug selection with medication trays.

October 19, 2016

Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature.

March 29, 2017

Communication through the electronic health record: frequency and implications of free text orders.

July 29, 2020

Critical events in the lives of interns.

November 19, 2008

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

March 6, 2005

A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors.

June 27, 2018

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Strategies used by nurses to recover medical errors in an academic emergency department setting.

June 14, 2006

Cardiac surgery errors: results from the UK National Reporting and Learning System.

February 16, 2011

Emergency department medication lists are not accurate.

November 12, 2008

Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU.

December 5, 2012

Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

July 17, 2019

Related Resources

Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS.

April 17, 2024

Implementation of medication reconciliation in outpatient cancer care.

August 9, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Patient Safety Innovations

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

May 31, 2023

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

April 12, 2023

Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.

March 29, 2023

Improving medication reconciliation in hospitals.

August 31, 2022

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

Medicines reconciliation in the emergency department: important prescribing discrepancies between the shared medication record and patients' actual use of medication.

March 16, 2022

Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical trial.

October 6, 2021

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

March 24, 2021

Longitudinal medication reconciliation at hospital admission, discharge and post-discharge.

August 26, 2020

AHRQ Health Information Technology Research: 2018 Year in Review.

October 23, 2019

Perspective

Medical Scribes and Patient Safety

August 1, 2019

Medication accuracy in electronic health records for microbial keratitis.

June 12, 2019

A Crisis in Health Care: A Call to Action on Physician Burnout.

January 30, 2019

Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency.

January 16, 2019

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

December 19, 2018

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

Resource-based view on safety culture's influence on hospital performance: the moderating role of electronic health record implementation.

September 19, 2018

A usability and safety analysis of electronic health records: a multi-center study.

September 19, 2018

Resolving the productivity paradox of health information technology: a time for optimism.

June 6, 2018

AHRQ Health Information Technology Division's 2017 Annual Report.

May 30, 2018

Adherence to recommended electronic health record safety practices across eight health care organizations.

May 16, 2018

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

May 9, 2018

How DeKalb Medical fixed drug safety problems after fatal error.

May 9, 2018

Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.

May 2, 2018

See More About The Topic

Hospitals

Facility and Group Administrators

Information Professionals

Medicine

Medication Errors/Preventable Adverse Drug Events

Higher accuracy of complex medication reconciliation through improved design of electronic tools.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Higher accuracy of complex medication reconciliation through improved design of electronic tools.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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

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