Missed diagnosis of stroke in emergency medicine settings is an important patient safety problem. In this study, researchers interviewed emergency medicine physicians about their perspectives on diagnostic neurology and use of clinical decision support (CDS) tools. Themes emerged related to challenges in diagnosis, neurological complaints, and challenges in diagnostic decision-making emergency medicine, more generally. Participating physicians were enthusiastic about the possibility of involving CDS tools to improve diagnosis for non-specific neurological complaints.
Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.
Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.
This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.
Vandenberg AE, Kegler M, Hastings SN, et al. Int J Qual Health Care. 2020;32:470-476.
This article describes the implementation of the Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) medication safety program at three academic medical centers. EQUIPPED is a multicomponent intervention intended to reduce potentially inappropriate prescribing among adults aged 65 and older who are discharged from the Emergency Department. The authors discuss lessons learned and provide insight which can inform implementation strategies at other institutions.
Use of data can improve the response of clinicians to patient concerns and deterioration. This article discusses how data surveillance can provide insights at the point of care to inform action and improve safety.
Vidrine R, Zackoff M, Paff Z, et al. Jt Comm J Qual Patient Saf. 2020;46:299-307.
Early recognition and treatment of sepsis is a critical safety issue. The authors of this study aimed to reduce the frequency of delayed sepsis recognition in a pediatric intensive care unit (PICU) through the use of an automated clinical decision support tool (CDS) prompting multidisciplinary sepsis huddles. After a two-year period, the average number of days between episodes of delayed sepsis recognition improved from one episode every 9 days to one every 28 days, and the median time to antibiotics decreased from 1.53 hours to 1.05 hours, representing a significant reduction.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use.
Carayon P, Hoonakker P, Hundt AS, et al. BMJ Qual Saf. 2020;29:329-340.
This simulation study assessed whether integrating human factors engineering into a clinical decision support system can improve the diagnosis of pulmonary embolism (PE) in the ED. Authors found that this approach can improve the PE diagnostic process by saving time, reducing perceived workload and improving physician satisfaction with the technology.
Gordon L, Grantcharov T, Rudzicz F. JAMA Surg. 2019.
Advances in technology enable real-time intraoperative data capture to prevent adverse events and improve patient safety and recovery. This commentary describes a surgical innovation that combined artificial intelligence, video technology, and clinical decision support and was designed to flag potential bleeding events in the surgical suite.
Wong A, Rehr C, Seger DL, et al. Drug Saf. 2019;42:573-579.
Although clinical decision support is intended to improve safety, decision support alerts often result in alert fatigue and overrides. This prospective observational study examined overrides for exceeding the maximum dose of a medication in the intensive care unit. Researchers determined that insulin was the most frequent medication for which a maximum dosage alert was overridden. In almost 90% of cases, the overrides were deemed clinically appropriate. The authors conclude that more intelligent clinical decision support for medication dosing is needed to balance safety with alert fatigue in the intensive care unit. A past PSNet perspective discussed the challenges of implementing effective medication decision support systems.
Wong A, Amato MG, Seger DL, et al. BMJ Qual Saf. 2018;27:718-724.
Clinical decision support systems in electronic health records (EHRs) aim to avert adverse events, especially medication errors. However, alerts are pervasive and often irrelevant, leading patient safety experts to question whether their modest improvement in safety outweighs the harms of alert fatigue. This study assessed provider overrides of a commercial EHR's medication alerts in intensive care units at one institution. Providers overrode most alerts, and the majority of those overrides were appropriate. Inappropriate overrides occasionally led to medication errors and did so more frequently than appropriate overrides. A recent WebM&M commentary recommends employing human factors engineering to make clinical decision support more effective.
Wong A, Amato MG, Seger DL, et al. J Crit Care. 2017;39:156-161.
This retrospective study reviewed more than 47,000 overridden medication alerts and found that the vast majority of overrides were clinically appropriate and did not cause harm. From this sample, 7 adverse drug events were identified, and these events were more likely when the alerts were overridden in error. This study demonstrates the challenge of identifying clinically important alerts in a setting where alert fatigue is common.
Prgomet M, Li L, Niazkhani Z, et al. J Am Med Inform Assoc. 2017;24:413-422.
While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.
How to tailor warnings within electronic health records to avert safety problems while avoiding alert fatigue is an ongoing question for medical informaticians. This study found that pop-up alerts appeared to be the most effective mechanism for presenting clinical decision support for drug prescribing.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-8.
Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.
Spina JR, Glassman PA, Simon B, et al. Med Care. 2011;49:904-10.
In contrast to most hospitals and clinics, the Veterans Affairs (VA) health care system has had a fully electronic health record with computerized provider order entry for several years. In this survey, VA physicians generally had positive impressions of the system, with nearly 90% feeling the system improved drug safety and nearly half reporting that serious drug interaction warnings were "very useful." However, the accuracy of drug–drug interaction and allergy warnings within this system are partially dependent upon clinicians manually entering medications prescribed by non-VA providers. As more than one quarter of respondents admitted to not always entering this data, this study highlights the importance of medication reconciliation in establishing accurate medication lists in the ambulatory care setting.
van Doormaal JE, Rommers MK, Kosterink JGW, et al. Qual Saf Health Care. 2010;19:e26.
This study describes the development of decision support algorithms designed to prevent prescribing errors within a computerized provider order entry system. The decision support system was developed and tested in comparison to errors identified by a trained pharmacist.
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