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Perspectives on Safety > Perspective
with commentary by Christopher Nemeth, PhD, Unintended Consequences, June 2011
This piece discusses how adopting new technology can have unintended effects.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
This article reports on two projects developed at the Center for Integration of Medicine and Innovative Technology that demonstrate functional device interoperability in hospital operating rooms.
Dyell D. Patient Saf Qual Healthc. January/February 2012;9:34-37.
This magazine article describes problems with medical devices and recommends that device connectivity and integration can improve safety.
Journal Article > Study
Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study.
Embi PJ, Leonard AC. J Am Med Inform Assoc. 2012;19:e145-e148.
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.
Journal Article > Study
Transcription errors of blood glucose values and insulin errors in an intensive care unit: secondary data analysis toward electronic medical record–glucometer interoperability.
Sowan AK, Vera A, Malshe A, Reed C. JMIR Med Inform. 2019;7:e11873.
This retrospective study examined possible transcription errors for blood glucose values among patients in a surgical intensive care unit for which glucometers did not connect with the electronic health record. Investigators identified multiple insulin dosing errors as a result of transcription errors. They spotlight the need for interoperability between glucometers and electronic health records.