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Approach to Improving Safety
Search results for "Electronic Health Records"
- Anesthesiology
- Electronic Health Records
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Journal Article > Study
Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.
Nair BG, Peterson GN, Newman S, Wu W, Kolios-Morris V, Schwid HA. Jt Comm J Qual Patient Saf. 2012:38;283-288.
This study advocates for a highly structured electronic health record with real-time alerts and designated team responsibility to improve documentation and compliance with perioperative beta-blocker administration.
Journal Article > Study
Integrating incident reporting into an electronic patient record system.
Haller G, Myles PS, Stoelwinder J, Langley M, Anderson H, McNeil J. J Am Med Inform Assoc. 2007;14:175-181.
This cohort study, conducted in an Australian hospital, reports on the implementation of an incident reporting system within an existing anesthesia electronic medical record. Anesthesiologists were required to document any adverse events, in one of 16 predefined categories, as part of their routine clinical documentation. Acceptance of the system was high, and the vast majority of reported adverse events were confirmed by chart review. As prior research has shown that incident reporting systems suffer from low physician reporting rates, integration of incident reporting into routine electronic documentation may help increase physician reports of errors.
Journal Article > Commentary
SNOMED CT: electronic health record enhances anesthesia patient safety.
Elevitch FR. AANA J. 2005;73:361-366.
The author presents SNOMED CT—a standardized clinical terminology—and its usefulness for electronic health records.
Cases & Commentaries
Falling Between the Cracks in the Software
- Web M&M
Julia Adler-Milstein, PhD; July/August 2016
Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.
Cases & Commentaries
DNR in the OR and Afterwards
- Web M&M
Bernard Lo, MD; September 2006
An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored.