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.
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.
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.
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.
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.
Lin C-P, Payne TH, Nichol P, et al. J Am Med Inform Assoc. 2008;15:620-6.
This study discovered that override rates of potentially critical adverse drug events remain problematic despite a clinical decision support system designed to prevent them. Investigators call for greater qualitative research to understand the interactions between these systems and the clinical providers who use them.
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