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Search results for "Active Errors"

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Web Resource > Multi-use Website

Computer-based Provider Order Entry--CPOE.

ClinfoWiki: The Clinical Informatics Wiki.

This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.

Web Resource > Government Resource

National Comparative Audit of Blood Transfusion.

National Blood Service Hospitals.

This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Journal Article > Study

Prescription errors related to the use of computerized provider order-entry system for pediatric patients.

Alhanout K, Bun SS, Retornaz K, Chiche L, Colombini N. Int J Med Inform. 2017;103:15-19.

Computerized provider order entry has been shown to decrease adverse drug events, but it can also introduce new medication errors. This retrospective study examined medication ordering errors intercepted by pharmacists for pediatric patients. As with prior studies in pediatrics, this investigation uncovered dosing errors associated with weight-based dosing, including calculation errors and missing weight information. The most common medication associated with errors was acetaminophen, which can cause severe harm if incorrectly dosed. The authors call for improving electronic health record prescribing interfaces, better user training, and enhancing communication among providers to prevent medication errors.

Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Journal Article > Commentary

A learning health care system using computer-aided diagnosis.

Cahan A, Cimino JJ. J Med Internet Res. 2017;19:e54.

Although advanced computing can assist in diagnosis, these systems are not routinely utilized. This commentary suggests a framework to develop diagnostic support technologies that capture physician knowledge to enhance diagnostic safety. The authors encourage drawing from crowdsourced data to guide improvements at a system level to address future practice and educational needs.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
  • Web M&M

Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Journal Article > Study

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

Wong A, Amato MG, Seger DL, et al. J Crit Care. 2017;39:156-161.

This retrospective study reviewed more than 47,000 overridden medication alerts and found that the vast majority of overrides were clinically appropriate and did not cause harm. From this sample, 7 adverse drug events were identified, and these events were more likely when the alerts were overridden in error. This study demonstrates the challenge of identifying clinically important alerts in a setting where alert fatigue is common.

Journal Article > Study

Learning from errors: analysis of medication order voiding in CPOE systems.

Kannampallil TG, Abraham J, Solotskaya A, et al. J Am Med Inform Assoc. 2017 Feb 17; [Epub ahead of print].

Although computerized provider order entry has been found to prevent some medication errors, simulation studies have also demonstrated that electronic prescribing platforms can introduce or fail to prevent medication errors. This retrospective electronic health record analysis examined medication orders that were canceled. Weekend and overnight orders were less likely to be voided than weekday or daytime orders. Pharmacist, nurse, and student orders were more likely to be canceled than physician orders. Comparing the clinician-provided reason for voiding an order with the more comprehensive information in the medical record, physicians found that clinicians' reported reasons for voiding orders were largely inaccurate. The authors suggest there is unrealized potential to characterize medication ordering errors using voided-order data.

Journal Article > Study

Meaningful use of health information technology and declines in in-hospital adverse drug events.

  • Classic

Furukawa MF, Spector WD, Limcangco MR, Encinosa WE. J Am Med Inform Assoc. 2017 Feb 16; [Epub ahead of print].

Electronic health records have both safety benefits and unintended consequences. This analysis used data from the 2010–2013 Medicare Patient Safety Monitoring System to compare the incidence of in-hospital adverse events among hospitals that did and did not meet meaningful use requirements for health information technology (IT), according to the Healthcare Information Management Systems Society Analytics Database. Investigators found that hospitals that met meaningful use criteria also reported fewer adverse events. Although the study design does not establish a causal relationship between implementation of health IT and the decline in adverse events, the authors argue that these advances in health IT contributed to this patient safety improvement.

Journal Article > Commentary

Responsible e-prescribing needs e-discontinuation.

Fischer S, Rose A. JAMA. 2017;317:469-470.

E-prescribing is a key strategy to improve medication safety by addressing illegible prescriptions, order omissions, and dosage confusion. However, there have been unintended consequences such as the inability to discontinue medications ordered electronically. This commentary reviews problems associated with this unintended consequence and suggests that enabling electronic cancellation of prescriptions can help address the issue. A WebM&M commentary discussed a case involving an electronic prescribing error.

Journal Article > Review

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.

Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.

Cases & Commentaries

Refused Medication Error

  • Web M&M

Mary Foley, PhD, RN; February 2017

A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.

Cases & Commentaries

Safeguarding Diagnostic Testing at the Point of Care

  • Web M&M

Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017

In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

Cases & Commentaries

The Hazards of Distraction: Ticking All the EHR Boxes

  • Spotlight Case
  • CME/CEU
  • Web M&M

Anthony C. Easty, PhD; February 2017

A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

Journal Article > Study

Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation.

  • Classic

Kostopoulou O, Porat T, Corrigan D, Mahmoud S, Delaney BC. Br J Gen Pract. 2017;67:e201-e208.

Improving diagnosis in outpatient care is a patient safety priority. This simulation study evaluated the process of diagnosis in the primary care setting. Investigators contrasted physicians' diagnostic accuracy conducting a primary care visit in their usual manner versus using a clinical decision support tool. Each visit employed a standardized patient (an actor reporting symptoms consistent with a given diagnosis) and the visits with and without decision support were matched for complexity. The tool improved diagnostic accuracy significantly: 68% of visits using decision support reached the correct diagnosis versus 59% of usual care visits. The duration of visits and number of subspecialty consultations did not change with or without decision support. Physician participants rated the usability of the decision support tool favorably overall. These data suggest that decision support can be feasibly integrated into primary care to improve diagnostic accuracy.

Journal Article > Study

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Journal Article > Study

E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.

Gabriel MH, Powers C, Encinosa W, Bynum JP. Med Care. 2017;55:456-462.

Hypoglycemia is a common and severe adverse drug event among patients with diabetes. This retrospective study of claims data found that Medicare patients with diabetes were less likely to be hospitalized or seen in the emergency department for hypoglycemia if their medications were prescribed electronically, compared to those receiving fewer or no electronic prescriptions. These findings add to the literature demonstrating the benefits of electronic prescribing.

Journal Article > Study

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

Bastawrous S, Carney B. J Digit Imaging. 2017;30:309-313.

Inadequate test result management is known to contribute to missed and delayed diagnosis. This Veterans Affairs study found that 0.17% of radiologic studies were not evaluated by radiologists. The study team identified several technical and process problems that contributed to these unread studies. They were able to address the issues to ensure all studies were read.

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