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Making electronic health records both SAFER and SMARTER.

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Johnson KB, Stead WW. JAMA. 2022;Epub Jul 14.

Electronic health record (EHR) system implementation should optimize interoperability and support clinician decision making. This commentary discusses a strategy to aid in the sociotechnical design of interfaces and involvement of the myriad of individuals that use EHRs, including patients.

Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions.

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Makic MBF, Stevens KR, Gritz RM, et al. Appl Clin Inform. 2022;13:621-631.

Many interventions targeting healthcare-acquired condition reduction and prevention target a single condition, rather than the risks of multiple conditions. This proof-of-concept study discusses clinician feedback on a proposed dashboard to enhance clinicians’ management combining the risks of multiple conditions (catheter-associated urinary tract infections, pressure injuries, and falls).

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

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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.

How health systems decide to use artificial intelligence for clinical decision support.

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Gonzalez-Smith J, Shen H, Singletary E, et al. NEJM Catalyst. 2022;3.

Clinical decision support (CDS) helps clinicians select appropriate medications, arrive at a correct diagnosis, and improve intraoperative decision making. Through interviews with health system executives, clinicians, and artificial intelligence (AI) experts, this study presents multiple perspectives on selection and adoption of AI-CDS in healthcare. Four emerging trends are presented: (1) AI must solve a priority problem; (2) the tool must be tested with the health system’s patient population; (3) it should generate a positive return on investment; and (4) it should be implemented efficiently and effectively.

Improving the specificity of drug-drug interaction alerts: can it be done?

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Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;79:1086-1095.

Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

Patient safety when receiving telephone advice in primary care - a Swedish qualitative interview study.

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Berntsson K, Eliasson M, Beckman L. BMC Nurs. 2022;21:24.

Safe and accurate telephone triage is of critical importance, particularly during the COVID-19 pandemic. This Swedish study evaluated district nurses’ experiences and perceptions of patient safety at a national nurse advice triage call center. Interviews with nurses resulted in an overall theme of “being able to make the right decision” based on the categories of “communication” and “assessment.”

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Interventions to reduce pediatric prescribing errors in professional healthcare settings: a systematic review of the last decade.

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Koeck JA, Young NJ, Kontny U, et al. Pediatric Drugs. 2021;23:223-240.

Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).

A Sweet Case of Hidden Hydrogen Ions

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April 28, 2021

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA.

Can decision support combat incompleteness and bias in routine primary care data?

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Kostopoulou O, Tracey C, Delaney BC. J Am Med Inform Assoc. 2021;28:1461-1467.

In addition to being used for patient-specific clinical purposes, data within the electronic health record (EHR) may be used for other purposes including epidemiological research. Researchers in the UK developed and tested a clinical decision support system (CDSS) to evaluate changes in the types and number of observations that primary care physicians entered into the EHR during simulated patient encounters. Physicians documented more clinical observations using the CDSS compared to the standard electronic health record. The increase in documented clinical observations has the potential to improve validity of research developed from EHR data.

Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization.

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Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Alert fatigue is a recognized contributor to task burden and medical error. This report distilled monitoring, analysis, and optimization experiences to recommend strategies for improving the effectiveness of clinical audible alerts which includes the development of an overarching clinical decision support governance plan.

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts.

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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.

Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial.

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Delvaux N, Piessens V, Burghgraeve TD, et al. Implement Sci. 2020;15:100.

Clinical decision support systems (CDSS) and computerized physician order entry (CPOE) have the potential to improve patient safety. This randomized trial evaluated the impact of integrating CDSS into CPOE among general practitioners in Belgium. The intervention improved appropriateness and decreased volume of laboratory test ordering and did not show any increases in diagnostic errors.

Associations of physicians’ prescribing experience, work hours, and workload with prescription errors.

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Leviatan I, Oberman B, Zimlichman E, et al. J Am Med Inform Assoc. 2021;28:1074-1080.

Human factors, such as cognitive load, are main contributors to prescribing errors. This study assessed the relationship between medication prescribing errors and a physician’s workload, successive work shifts, and prescribing experience. The researchers reviewed presumed medication errors flagged by a computerized decision support system (CDSS) in acute care settings (excluding intensive care units) and found that longer hours and less experience in prescribing specific medications increased the risk of prescribing errors.

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system.

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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.

Hospitals Can Take Key Steps to Improve Safe Use of Digital Systems.

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Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.

Tracking problems with health information technology (Health IT) is an important strategy to drive improvement. This report outlines general health IT and decision support actions to inform action, and discusses the role that regulation and accreditation have for driving improvement.

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

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McCradden MD, Joshi S, Anderson JA, et al. J Am Med Info Asso. 2020;27:2024-2027.

The authors discuss the challenges social inequalities pose to machine learning models, provide several recommendations for adopting ethical principles for the delivery of machine learning-assisted health care.

How real-time data can change the patient safety game.

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Diesing G. J AHIMA. 2020;July 1.

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.

When the Indications for Drug Administration Blur

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June 24, 2020

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.

Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing

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June 24, 2020

A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion.

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