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Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Journal Article > Study
Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.
In this study, investigators compared international normalized ratio measurements (INR, a measurement of blood clotting ability) obtained simultaneously on a point-of-care analyzer and a standard blood draw. Although the concordance between the two measurements met traditional quality assurance standards, the point-of-care analyzer results were systematically biased toward normal measurements, putting patients at risk of preventable adverse events due to failure to adjust anticoagulant medications appropriately.
Journal Article > Study
What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records.
Holden RJ. J Patient Saf. 2011;7:193-203.
This qualitative study identifies user, system, organizational, and environmental factors that help and hinder uptake of electronic health records.
Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.
This report highlights how working conditions can affect health care workers and recommends seven strategies for organizations to improve workplace safety.
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report.
Carayon P, Karsh B-T, Cartmill RS, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2010. AHRQ Publication No. 10-0098-EF.
The report summarizes evidence related to the impact of health information technology on workflow in outpatient settings.
Journal Article > Commentary
Patterson ES, Zhang J, Abbott P, et al. Jt Comm J Qual Patient Saf. 2013;39:129-135.
This commentary describes human factors, usability, and informatics recommendations for electronic health records in pediatrics to improve their usefulness and reduce the risk of errors.