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A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication. The program reduced overall medical errors, along with the incidence of several specific types of mistakes, including aspiration pneumonia (caused by entrance of foreign materials into the bronchial tree) and errors during management of shock.

Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21(5):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(7):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.
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia.
Vidrine R, Zackoff M, Paff Z, et al. Jt Comm J Qual Patient Saf. 2020;46(5):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.
After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended.
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(4):329-340.
This simulation study assessed whether integrating human factors engineering into a clinical decision support system to support 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.
Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of Medicine at the University of Michigan Medical School. His research focuses on improving the safety of hospitalized patients by preventing hospital-acquired complications—particularly those associated with peripherally inserted central catheters.
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(2):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.
Scheepers-Hoeks A-MJ, Grouls RJ, Neef C, et al. Artif Intell Med. 2013;59:33-8.
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.
A woman with new onset chest pain was admitted to the hospital. Although the computer readout of her electrocardiogram stated "***ACUTE MI***" at the top, the nursing assistant who performed the test placed it in the patient's bedside chart without notifying a nurse or physician. The patient was, in fact, having a myocardial infarction, whose treatment was delayed.