Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.  

In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.

Medical error affects the lives of patients, families, and members of the care team. Discussing an error that resulted in the death of a young man, this commentary reviews how cognitive bias and misdiagnosis contributed to the incident and the impact of the patient's death on his family, friends, and the physician who made the mistake. The authors highlight the use of autopsy results to identify the error.

… potential failures when introducing new equipment . … Miller KE, Arnold R, Capan M, et al. Improving Infusion Pump …

Health care professionals who experience emotional consequences after adverse events are considered second victims. This study presents a structured format for communication to debrief and support a health care team following an adverse event. Further work should examine whether this approach ameliorates negative consequences of adverse events for health care teams.

This commentary describes the development and implementation of a daily group phone call, guided by a unit leader, to facilitate discussion about patient safety concerns across a health system. The authors review the results and lessons learned in the 4 years following the intervention.

Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.