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Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.
Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
Grossman JM, Gourevitch R, Cross D. Washington, DC: National Institute for Health Care Reform; July 2014. NIHCR Research Brief No. 17.
According to this report, many vendors are still working to add and implement enhanced functions for electronic health records to support medication reconciliation capabilities. Health care workers are instead employing hybrid paper-electronic processes to ensure patients' medication lists remain accurate throughout their hospital stay.
Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study.
Avery T, Barber N, Ghaleb M, et al. London, UK: General Medical Council; May 2, 2012.
Examining prescription errors in general practices in England, this report suggests that information technology and incident reporting could address issues that persist since an earlier study.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.