Poor usability of electronic health record (EHR)-based computerized provider order entry (CPOE) can lead to adverse events. Using a newly developed self-administered assessment tool, researchers identified several EHR usability and safety issues across medication, laboratory, and radiology CPOE functions.

Reporting incidents and errors is a cornerstone of patient safety improvement efforts, but challenges remain, including low quality of reports and low rates of reporting. This article discusses the technological challenges of incident reporting and offers recommendations to improve usability in future reporting systems.

Prior studies have shown that adverse events can increase during the implementation of a new electronic health record (EHR) system. EHR transitions are remarkably expensive, laborious, personnel devouring, and time consuming. This article presents recommendations to facilitate transitions between one EHR system to another and opportunities for problem mitigation to avoid patient safety events.

This AHRQ-funded analysis of patient safety research found that research output—as measured by federal grant funding and peer-reviewed publications—increased sharply between 1995 and 2014. Publication of the To Err Is Human report and passage of federal budget stimulus funds were associated with an increase in patient safety publications and research funding.

Despite many technological innovations, safety events occur frequently in critical care settings. This observational study of critical care rounds found that more safety events occurred when technology such as computer alerts, phones, and pagers interrupted physicians. A previous WebM&M commentary discussed an incident involving a technology interruption that led to serious patient harm.

Improved health information technology (IT) event databases are necessary to better understand safety events associated with health IT, but such databases are lacking. This study describes the use of the Food and Drug Administration Manufacturer and User Facility Device Experience database as a source to identify adverse events related to health IT. Frequently identified contributing factors to such events included hardware and software problems as well as user interface design issues.

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.

An extensive body of literature documents the unintended consequences of information technology in the inpatient setting. This qualitative study identifies many similar unintended consequences after introduction of electronic health records into Australian nursing homes.

Through semi-structured interviews of home support workers in Canada, this study identified four intersecting types of home environment safety concerns: physical, spatial, interpersonal, and temporal.

This retrospective study found that nearly one quarter of incident reports lacked sufficient information to accurately classify and analyze the incident.

… the patient's role in safety . … Rathert C, Huddleston N, Pak Y. Acute care patients discuss the patient role in …

This study found few published articles in medical literature describing the legal protections for error disclosure by physicians. The authors suggest that this may reflect a need for greater awareness of the protections afforded by the Patient Safety and Quality Improvement Act.