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- Communication Improvement 13
- Culture of Safety 9
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- Error Reporting and Analysis 21
- Human Factors Engineering 14
- Legal and Policy Approaches 15
- Logistical Approaches 6
- Quality Improvement Strategies 21
- Research Directions 3
- Specialization of Care 2
- Teamwork 3
- Clinical Information Systems 37
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 8
- Identification Errors 4
- Interruptions and distractions 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 16
- Overtreatment 1
- Psychological and Social Complications 1
- Surgical Complications 2
- Surgery 2
- Nursing 1
- Pharmacy 10
- Health Care Executives and Administrators 70
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 69
- Patients 7
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Search results for "Book/Report"
- Technologic Approaches
Horsham, PA: Institute for Safe Medication Practices; 2019.
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur. This report provides comprehensive guidelines on the safe use of automated dispensing cabinets. Recommendations include improvement in areas such as stocking, labeling, and removal of expired medications.
Weiner J, Bao Y, Meisel Z. LDI/CHERISH Issue Brief. June 2017.
Health care has been exploring a variety of strategies to mitigate the opioid epidemic. Exploring the current state of prescription drug monitoring programs as one approach to reduce the misuse of prescribed opioids, this issue brief discusses the role of provider and patient behaviors, the potential for mandates to increase monitoring, and integration of monitoring systems into electronic health record technologies as avenues to support improvement.
Croskerry P, Cosby K, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
Efforts to enhance the reliability of the diagnostic process must take various elements into consideration. This publication discusses diagnosis, the role of reasoning in the process, challenges to diagnostic effectiveness, and strategies to make diagnosis more reliable such as patient engagement and using information technology.
Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.
Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.
Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.
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.
Lehmann CU, Séroussi B, Jaulent MC, eds. Yearb Med Inform. 2016;1:1-271.
Unexpected effects associated with implementation and use of health information technology (IT) are a recognized risk in care environments. This special issue includes studies, commentaries, and reviews exploring consequences of health IT, including unique problems such as hazards introduced when systems are down and the role of natural language processing in optimizing health information systems.
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.
Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.
Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology; 2016.
Washington, DC: National Quality Forum; February 2016.
Health information technology (IT) has transformed health care and improved patient safety, but it has also led to unintended consequences that increase the risk for patient harm. This comprehensive report from the National Quality Forum aims to define and prioritize measures of health IT–related safety so that issues can be quantified and monitored over time. The report identifies nine priority areas for measurement, ranging from tracking the extent of system interoperability to clinical decision support to patient engagement. For each area, the authors recommend using a previously published framework to examine three domains: data considerations like availability and interoperability; technology–work system interaction, such as usability, training, governance, and safety monitoring; and application of health IT to make care safer. The committee proposes to hold health IT vendors, health care organizations, and clinicians accountable for specific safety metrics for health IT systems. Although these measures require further development and testing, this report lays the foundation for more systematically evaluating the safety gains and concerns associated with widespread health IT implementation.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; February 2016.
Electronic health records have potential to improve health care, but they may also introduce unanticipated risks. This report describes the results of a group convened to explore strategies to enhance health IT safety. Focusing on copying and pasting health data from one record to another as the first area of concern, the report recommends enabling systems to identify what data has been copied in the electronic health record and where it came from, providing training to ensure the safe use of copy and paste, and regularly track and assess copying and pasting practices. The report includes tools to related to the recommendations. A WebM&M commentary explores the hazards associated with the use of copy and paste.
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.
Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.
Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.
The Institute of Medicine called for enhanced transparency in the reporting of health IT safety incidents to inform implementation and use of such technologies. This report reviews insights from a multidisciplinary task force that discussed how to design an entity focused on improving health IT–related safety that enables collaboration and learning.
Zheng K, Ciemins EL, Lanham HJ, Lindberg C. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.
Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.
Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
Wachter R. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463.
Over the past few years, driven by $30 billion of federal incentives to doctors and hospitals, the adoption rate for electronic health records has dramatically increased, from approximately 10% in 2008 to 70% today. In essence, health care has switched from being a primarily analog to a primarily digital industry. While evidence suggests that the digitization of health care is having a positive effect on safety and quality, many challenges and unanticipated consequences have emerged. Written by a national leader in patient safety, this book chronicles some of these, including physician dissatisfaction, changing relationships among providers and between providers and patients, new kinds of medical mistakes, and problems with clinician work flow. It also highlights some of the opportunities arising from increasingly engaged patients and the entry of Silicon Valley into the health care market. Ultimately, it paints a hopeful picture of where health care information technology may take us, making the case that this positive future state will depend on both the evolution of the software and on changes in culture, training, and the organization of the work.
Washington, DC: Leapfrog Group; March 2015.
National hospital quality reports aim to provide benchmarks on safety and other quality measures, though questions remain regarding their universal applicability to gauge improvement. This analysis of the 2014 Leapfrog Hospital Survey results found that while the majority of hospitals employed computerized provider order entry (CPOE), not all systems provided appropriate warnings to prevent potentially harmful orders, suggesting CPOE systems still need improvement to augment safety.
Banger A, Graber ML. Washington, DC: Office of the National Coordinator for Health Information Technology; February 2015.
Rapid implementation of health information technology (IT) has presented several unanticipated safety issues. This publication explores and summarizes the current evidence around health IT and patient safety. Despite reported challenges, the authors found that health IT enhances patient safety and suggest that future research should consider the unintended consequences of health IT use, particularly the effect of human and contextual factors on implementation.
Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960.