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- Communication Improvement 12
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Teamwork 2
- Clinical Information Systems
- Transparency and Accountability 1
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 1
- Medication Safety 7
- Psychological and Social Complications 3
- Surgical Complications 1
Search results for "Patients"
- Electronic Health Records
Schulte F, Fry E. Kaiser Health News, Fortune Magazine. March 18, 2019.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Lamas D. New York Times. March 27, 2018.
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread. Reporting on a physician's experience with a patient who nearly received an unwanted intubation due to poor electronic health record data quality and design, this newspaper article describes problems associated with lack of standards for advance care planning documentation and the inability to access advance directives.
Boodman SG. Washington Post. March 26, 2018.
Although providing patients with access to physician notes and test results supports transparency and patient engagement, it can also introduce certain challenges. This newspaper article reports on unintended psychological stresses associated with direct patient access to test results without appropriate contextual information. Improvement strategies include use of graphics, timely patient-centered communication, and scheduling appointments to discuss results. A PSNet perspective explored how patient-facing technologies can empower patients and improve safety.
Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Landro L. Wall Street Journal. September 12, 2017.
Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports on several areas of research and improvement efforts that seek to better understand the roots of diagnostic error and design solutions. Strategies discussed include artificial intelligence, lessons learned initiatives, and data-tracking mechanisms.
Landi H. Healthcare Informatics. June 1, 2017.
The use of copy and paste is a popular time-saving mechanism to update electronic medical documentation, but this practice can introduce risks. This news article reports on various resources that explore problems associated with the copying and pasting in electronic health records, including a recent study that highlighted how this practice can perpetuate incomplete or wrong information into patient records.
Xu R. The Atlantic. May 11, 2018.
Clinician burnout is a growing concern in health care. This magazine article illustrates how ineffective electronic health record systems contribute to the problem and recommends aligning systems and regulatory influences more tightly with actual practice workflow as a strategy for improvement. A past Annual Perspective discussed the impact of clinician burnout on patient safety.
Rowland C. Boston Globe. July 20, 2014.
Government incentives have led to rapid development and adoption of electronic health records (EHRs). This newspaper article examines some of the unintended consequences of implementing electronic systems that have not been fully optimized for use in the health care environment, such as serious adverse events and medication errors. Moreover, failure to mandate reporting of EHR-related errors hinders developing strategies to improve them. Although clinicians want to avoid returning to paper records, they find current electronic systems inadequate, difficult to use, and nonintuitive.
Landro L. Wall Street Journal. June 9, 2014.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
Gunderman R. The Atlantic. June 5, 2013.
This magazine article highlights the drawbacks of amassing information in electronic medical records, in that it may negatively influence real communication or clinicians' genuine understanding of the patient.
Terhune C. Los Angeles Times. August 3, 2012:B1.
This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and discusses risks associated with EMR systems.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Landro L. Wall Street Journal. June 7, 2011:D3.
Freudenheim M. New York Times. December 13, 2010:3B.
This article reports on a committee created by the Institute of Medicine to analyze the potential impact of electronic medical records (EMR) on costs and quality of care.
Landro L. Wall Street Journal. January 18, 2010;D5.
This column highlights the work of the Institute for Safe Medication Practices and other groups to raise awareness of medication safety issues, including an initiative to distribute error reports to practitioners, called the National Alert Network for Serious Medication Errors.
Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.
This article discusses an AHRQ-funded program to study information technology tools and their ability to minimize medication errors in a geriatric patient population.
Brown D. Washington Post. April 10, 2007:HE01.
This article describes the Veterans Affairs' universal medical records network and illustrates how use of electronic medical records at VA medical centers supports safe care.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Journal Article > Commentary
Health information technology is a vehicle, not a destination: a conversation with David J. Brailer.
Milstein A. Health Aff (Millwood). 2007;26:w236-w241.
Brailer, the National Coordinator for Health Information Technology ("the IT Czar") from 2004-2006, discusses the fundamental changes needed for the United States to optimize the use of health information technology, including patient ownership of their health care information, universal access to provider performance data, and changes in health care policy.