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Search results for "United States Federal Government"
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
Journal Article > Study
Automated identification of postoperative complications within an electronic medical record using natural language processing.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-855.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007. Publication No. NOT-HS-08-002.
Stout D. New York Times. June 17, 2006;National desk:9.
This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.
Journal Article > Study
Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis.
Hofer TP, Hayward RA. Ann Intern Med. 2002;137(pt 1):327-333.
The authors present the case of a patient with multiple medical problems who suffers complications related to decisions made by her providers during hospitalization. The case is used as background for exploration of the concept of errors, defining preventable ones, and the mechanisms by which organizations review such errors in an attempt to uncover systems solutions. Specifically, the authors discuss the reliability of diagnostic testing, the concept of hindsight bias, and the limitation of using resources such as root cause analysis in situations when causality is difficult to define. This article is part of "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.