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.
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.
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.
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.
Terrell KM, Perkins AJ, Dexter PR, et al. J Am Geriatr Soc. 2009;57:1388-94.
Elderly patients are particularly vulnerable to adverse drug events. This randomized trial used a decision support system coupled with computerized provider order entry to target prescribing of potentially inappropriate medications to elderly patients in an urban emergency department. Physicians who received alerts warning them of a drug's potential adverse effects were significantly less likely to prescribe potentially harmful medications. Although prior studies of computerized reminders have found that physicians frequently ignore reminders, in this study decision support alerts were accepted nearly half the time, and alerts were generally rejected for valid reasons (for example, the patient had tolerated the medication previously). The challenges of implementing effective medication decision support systems are discussed in an AHRQ WebM&M perspective.
Kadmon G, Bron-Harlev E, Nahum E, et al. Pediatrics. 2009;124:935-940.
Hospitalized children are particularly vulnerable to medication errors due to the complexity of weight-based dosing and the resulting potential for calculation errors. Computerized provider order entry (CPOE) has been widely advocated as a means of preventing such errors. In this study, implementation of a CPOE system did not initially reduce adverse drug events in a pediatric intensive care unit. However, when a decision support system for calculating weight-based dosages was added to the CPOE system, medication errors declined significantly. A 2008 Sentinel Event Alert published by The Joint Commission highlighted the prevalence of pediatric medication errors and recommended potential solutions.
An electronic system was developed in order to ensure correct assignment of hospitalist physicians to patients at admission and at the time of care transitions (e.g., discharge from the intensive care unit).
Hravnak M, Edwards L, Clontz A, et al. Arch Intern Med. 2008;168:1300-8.
A continuous physiologic monitoring system appeared to detect physiologic instability earlier than standard monitoring techniques. Prior research has questioned the false negative rate of such systems, but that problem was not noted in this study.
Sard BE, Walsh KE, Doros G, et al. Pediatrics. 2008;122:782-787.
Standardizing care processes, through the use of checklists and other approaches, has been demonstrated to improve patient safety by reducing health care–associated infections and handoff errors. This study implemented a standardized "quicklist" of commonly used pediatric medications within an existing computerized provider order entry system. Although use of the quicklist was not mandatory, prescribing errors were significantly reduced, especially among those providers who used the quicklist regularly. The study provides an example of how standardization combined with decision support can improve medication safety.
Ramnarayan P, Cronje N, Brown R, et al. Emerg Med J. 2007;24:619-24.
Diagnostic errors are common and often related to cognitive processes, with many retrospectively discovered through review of closed malpractice claims or at time of autopsy. This study used a web-based clinical decision support system called Isabel to determine its ability to accurately diagnose acute medical problems compared with final discharge diagnoses and a panel of experts. Building on a past study, investigators discovered that the system displayed the final discharge diagnosis in 95% of inpatients. The authors highlight the potential benefits of integrating such a system into daily practice and call for further study on whether it reduces diagnostic error. An AHRQ WebM&M conversation with Dr. Britto, the co-founder of Isabel Healthcare Inc., discusses eradicating diagnostic errors through such decision support systems.
Vardi A; Efrati O; Levin I; Matok I; Rubinstein M; Paret G; Barzilay Z.
The authors describe the implementation of computerized physician order entry with decision support in one pediatric hospital. After the system was in place, no resuscitation medication errors transpired.
The author describes changes made within the neonatal intensive care unit to improve medication use safety, including eliminating the "rule of 6" for medication preparation and installing smart pump technology.
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