The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
… practices that appear to result in safer scribe systems. … DeborahWoodcock, MS, MBA … Health Informatics Specialist Vancouver, … some of the potential patient safety ramifications. … Dr. Robert Wachter … : What motivated you to think about …
This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
Dr. Smith is Chief Faculty Practices Officer for UCSF Health and a family medicine physician. Over the past 3–4 years, the health system has implemented a robust program using medical scribes in the outpatient setting. We spoke with her about her experience implementing this program, including the benefits and some of the potential patient safety ramifications.
Ash JS, Singh H, Wright A, et al. Health Informatics J. 2019:1460458219833109.
This direct observation and interview study examined safety activities associated with electronic health records. The study team identified decision making, organizational learning, and frontline user engagement (including clinical decision support and training) as the three critical areas for safe use of electronic health records.
Bordley J, Sakata KK, Bierman J, et al. Crit Care Med. 2018;46:1570-1576.
The electronic health record has become an integral part of daily work in the intensive care unit, including interprofessional rounds. This study sought to test whether safety problems documented in a simulated patient electronic health record were recognized and discussed on rounds. Residents, nurses, and pharmacists conducted simulated rounds on the patient. Overall, about 69% of issues were detected. Residents identified more of the safety issues than nurses or pharmacists, but the teams recognized more issues than any of the individual disciplines did on their own. An accompanying editorial emphasizes the need for electronic health records to process data instead of serve as "bottomless collections of data."
Tolley CL, Forde NE, Coffey KL, et al. J Am Med Info Assoc. 2017;25:575-584.
This systematic review of medication errors in pediatrics settings with computerized provider order entry identified key vulnerabilities in electronic prescribing. Lack of drug dosing alerts, inappropriate alerting, dropdown menu option errors, and overarching problems such as the lack of appropriate dosing choices for specific medications contributed to errors across the included studies. The authors call for more advanced decision support to address these concerns.
Wright A, Ai A, Ash JS, et al. J Am Med Inform Assoc. 2018;25:496-506.
Clinical decision support (CDS) includes electronic alerts that can prevent errors. Excessive or erroneous alerts may lead to alert fatigue or other unintended consequences. Researchers used a blend of qualitative methods such as interviews and quantitative data like alert rates to develop a taxonomy of CDS alert errors. The taxonomy includes the origin of the error, which most commonly occurred with introduction of a new decision support rule, and describes the underlying reason for the error, such as problems with new terms, conceptualization, and building the rule as intended. Errors could cause an alert to fail to appear for a relevant situation or could cause an irrelevant or erroneous alert to appear. Most errors came to light through reports from users. The authors recommend classifying CDS alert errors using this taxonomy so that safety efforts will be consistent and actionable.
Schreiber R, Sittig DF, Ash JS, et al. J Am Med Inform Assoc. 2017;24:958-963.
Lack of interoperabilty and user errors are safety concerns associated with the use of electronic health records (EHRs). This case report provides two examples of problems with order cancellations in EHRs due to ineffective interfacing of systems that led to gaps in care. The authors recommend that hospitals test new information technologies to help identify weaknesses and make the ordering process safer.
Woodcock D, Pranaat R, McGrath K, et al. Stud Health Technol Inform. 2017;234:382-388.
The use of scribes, nonclinical staff who aid clinicians by entering information into electronic health records (EHRs), has increased markedly in the past few years. This qualitative study used interviews with clinicians, administrators, and scribes to develop a sociotechnical framework for the role of scribes with relation to the EHR. A prior commentary suggested that scribes represent a workaround that may inhibit the development of more advanced and user-friendly EHRs.
Brown CL, Mulcaster HL, Triffitt KL, et al. J Am Med Inform Assoc. 2016;432-440:432-440.
The use of computerized provider order entry (CPOE) systems, in which clinicians place orders for tests, labs, and medications electronically, has grown rapidly in both inpatient and outpatient settings. Although research has shown that implementation of CPOE can reduce prescribing errors in both inpatient and outpatient settings, additional studies have found that errors continue to occur. In this systematic review, researchers identified multiple factors linked to CPOE prescribing errors, including flaws in functional design and underlying clinical decision support systems, as well as insufficient system flexibility leading to user workarounds. The authors suggest that further consideration must be given to human factors design principles. A recent Annual Perspective highlighted some of the ongoing challenges associated with CPOE.
Nanji KC, Rothschild JM, Boehne JJ, et al. J Am Med Inform Assoc. 2014;21:481-6.
Computerized provider order entry (CPOE) systems have been widely implemented to prevent adverse drug events due to prescribing errors. This direct observation and interview study in an outpatient pharmacy setting describes changes in practice as a result of electronic prescribing. Consistent with prior studies investigating unintended consequences of CPOE, researchers identified new errors associated with electronic prescribing, as well as potential methods to reduce adverse drug events. To improve safety, the authors recommend developing systems to track abandoned prescriptions, offering incentives for pharmacies to utilize electronic prescribing, and enhancing the interface between electronic health record and pharmacy computer systems to decrease manual entry, limit duplicated prescriptions, and expedite clarification requests. A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong patient and deleted it, mistakenly assuming it would cancel the order.
Campbell EM, Guappone KP, Sittig DF, et al. J Gen Intern Med. 2009;24:21-6.
Prior studies have demonstrated unintended consequences associated with implementing computerized provider order entry (CPOE) systems. This qualitative study used direct observation and interviews to characterize the types of work flow disruptions associated with CPOE.
Ash JS, Sittig DF, Dykstra RH, et al. Int J Med Inform. 2008;78.
Prior research has identified nine types of unintended consequences of computerized provider order entry, including alterations in normal physician workflow and creation of extra work for providers. This study documents a high incidence of these problems in a variety of hospitals and discusses strategies for avoiding or mitigating these issues.
Sittig DF, Ash JS, Guappone KP, et al. Int J Med Inform. 2008;77:440-7.
This study surveyed clinicians to gauge their concerns about computerized provider order entry (CPOE) prior to implementation. The authors discovered that the most common unintended consequences anticipated were more or new work for clinicians, workflow issues, and never-ending system demands.
Ash JS, Sittig DF, Poon EG, et al. J Am Med Inform Assoc. 2007;14:415-23.
While implementation of computerized provider order entry systems is widely recommended, prior research has raised the concern that CPOE may lead to unintended effects on patient safety. In this study, the authors sought to classify the frequency of unintended consequences—positive and negative—encountered in hospitals that have implemented CPOE. Unintended consequences were classified based on the authors' previously developed taxonomy. Survey respondents felt that unintended consequences were widespread, primarily relating to changes in provider workflow and communication. Failure to anticipate these issues may have played a role in widely publicized instances of problems with CPOE implementation.
Campbell EM, Sittig DF, Ash JS, et al. J Am Med Inform Assoc. 2006;13:547-56.
This qualitative study describes the capture and analysis of computerized provider order entry (CPOE)–related events from five different CPOE sites. Building on an initial set of examples from an expert panel, investigators designed a 9-category classification scheme for nearly 325 unintended consequences reported. The most frequent unintended consequences included more or new work for clinicians, workflow issues, and never-ending system demands. The authors discuss strategies to address each of the categories and explain the importance of understanding these issues to advance management of future CPOE applications. A past study and commentary discussed the need for caution with implementation of CPOE systems in light of similar concerns and available research.
Ash JS, Berg M, Coiera E. J Am Med Inform Assoc. 2004;11:104-12.
The authors draw from their aggregated experience in qualitative assessment of clinical information systems in the United States, Europe, and Australia to propose a framework for understanding unexpected adverse consequences of patient care information systems (PCIS) on clinical work. The adverse effects are broadly divided into errors in the process of entering and retrieving information in or from the system and errors in the communication and coordination processes that the PCIS is intended to support. The authors highlight the mismatch between the linear, rigid design of software and the cognitive, social, and organizational realities of health care delivery. The article was among the first and most influential in a wave of papers highlighting potential drawbacks in clinical information technology, and tempering the impression of computerized provider order entry systems as a universal good.
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