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- Error Reporting and Analysis
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- Quality Improvement Strategies 1
- Technologic Approaches 3
Search results for "Information Professionals"
Journal Article > Study
Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database.
Zhan C, Hicks RW, Blanchette CM, Keyes MA, Cousins DD. Am J Health Syst Pharm. 2006;63:353-358.
Risk of electromagnetic interference with medical telemetry systems operating in the 460-470 MHz frequency bands.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 16, 2005.
This announcement notifies health care practitioners of possible interference with medical alarms and patient monitoring systems caused by mobile radio transmitters.
Journal Article > Study
Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.
This AHRQ-funded project describes the development of a national Web-based anatomic pathology database and how the information captured provided opportunities for intervention. Investigators first categorized the data into error types and frequency and also estimated the discrepancy rates with interpretation of recorded specimens. Subsequent root cause analyses identified system factors that contributed to the errors, and the authors share several quality improvement strategies implemented in response. While the study data derive only from self-reported institutional errors, the opportunity to expand the process to additional institutions may identify shared system deficiencies or specific error types that warrant greater attention. The process outlined resembles in many ways the efforts of reporting systems in general as a mechanism to learn and improve from past experiences with errors.
Journal Article > Commentary
Holzmueller CG, Pronovost PJ, Dickman F, et al. J Am Med Inform Assoc. 2005;12:130-139.
This commentary discusses the development of an Intensive Care Unit Safety Reporting System (ICUSRS), an endeavor funded by AHRQ. The authors outline the context for improved reporting systems in intensive care units (ICUs), current challenges, and the benefits of a web-based platform. They discuss how reports are generated, collected, and ultimately disseminated back to frontline staff using the system. They report on the system's early success in 18 ICUs and express their commitment to expanding the application of this tool to improve patient safety.