Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.

This review of the evidence on nursing handoffs identifies areas where more research is needed to understand the content and context of the information communicated during transitions.

The commonly used expression "missing the forest for the trees" is a shorthand summary of the concept of situational awareness—the degree to which a clinician's perception matches reality. Situational awareness requires that clinicians can perceive the information they need, comprehend the importance of this information, and forecast the implications of this information (i.e., adverse consequences that might happen). Nurses' role in patient safety is largely dependent on maintaining situational awareness, and this study used direct observation of intensive care unit (ICU) nurses in three hospitals to assess the degree to which monitoring devices and other information displays supported each phase of situational awareness. The authors found that the design of bedside information displays often impaired nurses' ability to gather critical patient data, particularly around medications, resulting in the potential to harm situational awareness. The authors make recommendations, based on human factors engineering principles, to improve the quality of information displays in the ICU.

This study evaluated the quality of systematic reviews that were designed to measure the impact of computerized provider order entry on clinical outcomes. The authors rate the reviews as moderate and draw a series of recommendations for future such analyses.

By enhancing providers' ability to transmit information in a concise and standardized fashion, electronic medical records (EMR) offer great promise for improving handoffs and signouts. However, this analysis of nursing handoffs at an institution with a commercial EMR found that the built-in patient summaries provided inadequate detail and flexibility for clinical signout purposes, forcing nurses to develop workarounds for transmitting key information. This finding reveals the importance of human factors engineering in designing information technology solutions for patient safety problems.

Direct observation of nursing shift change revealed that recommended standards for safe signouts were frequently not followed.

This review analyzes research on the impact of computerized provider order entry and recommends that future studies enhance design and improve measurement techniques.