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.
Using root cause analysis data submitted to the Veterans Affairs (VA) National Center for Patient Safety from 2013 to 2018, this study analyzed health information technology (HIT)-related outpatient diagnostic delays to identify common safety concerns. The study identified five high-risk areas for diagnostic delays involving HIT: managing electronic health record inbox notifications and communications, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Inform Asso. 2020.
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.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Yang Y, Ward-Charlerie S, Dhavle AA, et al. J Manag Care Spec Pharm. 2018;24:691-699.
Electronic prescribing has yielded unequivocal improvement in outpatient medication safety. However, electronic health record prescribing infrastructure differs substantially, which creates safety hazards when prescribers transmit information to pharmacies. Researchers examined 25,000 prescriptions sent to a retail pharmacy chain and described variation in the Sig line—prescriber instructions for how a patient should use a medication. The 501 separate electronic prescribing systems generated 832 different ways to communicate the simple instruction: "Take 1 tablet by mouth daily." About 10% of prescriptions posed a potential safety hazard. An AHRQ tool provides standard language to clarify directions for patients regarding how to take their medications. A previous WebM&M commentary discussed strategies for pharmacies, clinics, and providers to mitigate the risk of patient confusion.
Nelson CE, Selbst SM. Pediatr Emerg Care. 2015;31:368-72.
According to this retrospective chart review study, clinically significant prescription errors continued to occur at an alarming rate in a pediatric emergency department, despite the introduction of computerized provider order entry. Emergency medicine residents made more prescribing errors than pediatric residents.
Carayon P, Wetterneck TB, Cartmill R, et al. BMJ Qual Saf. 2014;23:56-65.
As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.
This study characterizes the types of medication errors documented after introduction of a comprehensive electronic medication management system (that included computerized provider order entry) at two Australian hospitals.
Savage I, Cornford T, Klecun E, et al. BMC Health Serv Res. 2010;10:135.
This study used a mixed-methods approach, including structured interviews with staff and patients, to determine the types of errors associated with a newly implemented computerized provider order entry system.
Adams M, Bates D, Coffman G, et al. Boston, MA: Massachusetts Technology Collaborative; New England Healthcare Institute; February 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-30.
The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.
Karnon J, McIntosh A, Dean JE, et al. Saf Sci. 2006;45.
The authors describe a model used to predict rates of preventable adverse drug events and assess the effectiveness of interventions for reducing those errors, including computerized physician order entry, pharmacists on ward rounds, and barcoding.
In this study, nurses at a Veterans Affairs hospital were surveyed regarding their experiences with medication errors and their perception of the effect of computerized physician order entry (CPOE) and bar code medication administration (BCMA) on the incidence of errors. Nurses identified many reasons for medication errors, including fatigue and illegible physician handwriting. While most nurses had filed an incident report due to a medication error, the majority agreed that some errors go unreported due to fear of criticism from management or colleagues. The implementation of CPOE and BCMA was associated with a lower perceived incidence of errors.
Kim GR, Chen AR, Arceci RJ, et al. Arch Pediatr Adolesc Med. 2006;160:495-8.
This study utilized a multidisciplinary team of oncology providers to conduct a failure mode and effects analysis (FMEA) and generate recommendations for implementing a computerized provider order entry (CPOE) system. Investigators tracked more than 1000 chemotherapy orders before and after CPOE implementation and discovered lower rates of ordering errors with the new process. Discussion includes specific recommendations that resulted from the FMEA and presentation of the error types (eg, order and treatment plan match, correct calculation, nursing checklist present) noted during the study period. The authors acknowledge the importance of CPOE as a tool to reduce chemotherapy-related medication errors and advocate for close collaboration among clinical and information technology experts to drive such interventions.
Han YY, Carcillo JA, Venkataraman ST, et al. Pediatrics. 2005;116:1506-12.
Although computerized physician order entry (CPOE) prescribing systems are commonly believed to improve patient safety and outcomes, this single-hospital study discovered increased mortality rates after implementation. Investigators retrospectively analyzed several variables in the 13 months before and 5 months following implementation. Even after adjustment for mortality variables, CPOE was independently associated with 3.28 greater odds for mortality. Additional findings include the workflow challenges and increased time required to enter orders compared with traditional handwritten practices. Given the national interest in CPOE, these findings should reinforce the understanding that CPOE is a tool rather than a solution for patient safety and that appropriate vigilance in implementation is necessary.
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