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Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.
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.
Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.
Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.
Shah SN, Amato MG, Garlo KG, et al. J Am Med Inform Assoc. 2021;28:1081-1087.
Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. Over a one-year period, this study found that medication-related CDS alerts associated with renal insufficiency were nearly always deemed inappropriate and were all overridden. These findings highlight the need for improvements in alert design, implementation, and monitoring of alert performance to ensure alerts are patient-specific and clinically appropriate.  
Kuitunen SK, Niittynen I, Airaksinen M, et al. J Patient Saf. 2021;17:e1669-e1680.
The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.
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.
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.
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
Lowenstein EJ, Sidlow R. J Dermatol. 2018;179:1263-1276.
Cognitive shortcuts, or heuristics, are often used by experts to make decisions. This two-part review examines how heuristics affect diagnosis in dermatology. The first article discusses the strengths and weaknesses in visual diagnosis behaviors. The second recommends techniques for improving decision making and self-awareness of thought processes to avoid diagnostic error in dermatology practice.
Challen R, Denny J, Pitt M, et al. BMJ Qual Saf. 2019;28:231-237.
Artificial intelligence (AI) has the potential to improve health care. This narrative review summarizes short-, medium-, and long-term safety concerns associated with AI implementation in medical care. The authors provide quality control questions to help those involved in developing AI systems detect areas of concern.
Powers EM, Shiffman RN, Melnick ER, et al. J Am Med Inform Assoc. 2018;25:1556-1566.
Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.
Tolley CL, Slight SP, Husband AK, et al. Am J Health Syst Pharm. 2018;75:239-246.
This systematic review of clinical decision support for safe medication use found that such systems are incompletely implemented and lack standardization and integration of patient-specific factors. The authors suggest that reducing alert fatigue and employing human factors principles would enhance decision support effectiveness.
Her QL, Amato MG, Seger DL, et al. J Am Med Inform Assoc. 2016;23:924-33.
Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.
Payne TH, Hines LE, Chan RC, et al. J Am Med Inform Assoc. 2015;22:1243-50.
Clinical decision support alerts can help identify potential drug–drug interactions, but they can also contribute to alert fatigue. This commentary provides recommendations to inform the design of decision support to address drug–drug interactions. The authors suggest that improvement strategies focus on standardizing terminology and visual cues.
Cho I, Slight SP, Nanji KC, et al. Int J Med Inform. 2015;84:630-9.
Prior studies have shown that prescribing clinicians frequently override computerized alerts warning them of potentially harmful drug interactions. This study found that house staff and physicians with fewer patient encounters were more likely to ignore alerts—as were physicians who graduated from one of the top five medical schools in the United States. Understanding why clinicians override warnings is critical to combating alert fatigue.

Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.

Articles in this special issue cover efforts to reduce diagnostic errors, including patient engagement and cognitive debiasing.
Prewitt J, Schneider S, Horvath M, et al. J Patient Saf. 2013;9:103-9.
Patient-controlled analgesia (PCA) devices were designed to provide safe administration of opiate analgesics, but PCA-related medication errors do still occur. Due to the dangers associated with opiate use, these errors can be fatal. This study provides a retrospective review of PCA adverse drug events at Duke University Hospital before and after implementation of clinical decision support with computerized provider order entry and PCA smart pump technology. The rate of adverse drug events per 1000 patient PCA days decreased from 5.3 (pre-intervention) to 4.2 (post-intervention). This modest but important improvement supports medical centers' investment in these strategies. A prior AHRQ WebM&M commentary discusses a case of a fatal PCA overdose.
Embi PJ, Leonard AC. J Am Med Inform Assoc. 2012;19:e145-8.
Clinical decision support systems (CDSS) are being applied widely in patient safety, most frequently to provide alerts intended to prevent medication errors. The utility of such warnings is limited by alert fatigue—clinicians' tendency to ignore repeated alerts. This study of an alert within an electronic medical record designed to encourage participation in a clinical trial is relevant for CDSS designers, as it quantifies the degree of alert fatigue. The study found that response rates to the alert declined consistently over time in response to increased exposure to the alert. A recent commentary called for CDSS to be tailored to maximize safety outcomes while minimizing alert fatigue.