… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … This head-to-head comparison of two …

Prior research has shown that providers frequently override drug interaction alerts, sometimes as a result of alert fatigue. In this study, researchers observed providers as they completed medication orders, addressing both high- and low-severity drug interaction alerts using five distinct electronic health records in two countries. The authors found that providers engaged in complex clinical reasoning prior to declining an alert, balancing various aspects of patient care including safety- and patient-specific factors.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Clinical decision support alerts can …

Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A Perspective interview with Dr. Pat Croskerry explored the role of cognition in medical error.

The patient safety risks associated with handoffs have been well documented. As a result, multiple investigators have developed standardized tools to improve the quality of information transfer during handoffs. What remains unclear is the extent to which standardizing the handoff process improves patient safety. This systematic review of 36 studies examining the effectiveness of handoff tools found that most tools were not evaluated rigorously and did not specifically assess the effect of standardizing handoffs on patient-level outcomes. Therefore, the authors were unable to reach conclusions regarding the optimal methods for improving the quality of handoffs. Similar problems were noted in studies of checklists, another widely implemented safety intervention, highlighting both the difficulty and the importance of strictly evaluating patient safety interventions.

… Journal of biomedical informatics … J Biomed Inform … Direct observation of handoffs in the …

This retrospective study found that most preventable adverse drug events that arose from inadvertent drug duplication or drug–drug interaction could have been prevented through the use of existing decision support systems.

This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.

This study explored information signals and their interpretation by pharmacists to better understand their reasoning in generating hypotheses about adverse drug events.

This review article describes approaches to safety improvement that specifically address the complex nature of the clinical health care environment.

This qualitative study reported the user, pump design problems, and lack of training as the most frequent factors attributed to adverse events with medical devices.

… International Journal of Medical Informatics … Int J Med Inform … This study describes several instances of near …

… International journal of medical informatics … Int J Med Inform … The investigators shadowed emergency …

In this prospective study of psychiatric emergency care, the researchers analyzed audiotaped interactions that included miscommunication incidents or perceived violations of accepted practice to identify potential errors.

The researchers found that computerized decision support for pediatric medication dosing was not effective in altering orders.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … The authors identify the challenges …

… Int J Med Inform … IntJ Med Inform … This study evaluated factors …

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Implementation of computerized …

In this AHRQ-funded study, the investigators sought to increase acceptance of alerts by devising specific decision support for the ambulatory care setting, with only critical alerts interrupting clinician workflow.