Narrow Results Clear All
- Communication Improvement 9
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 4
- Logistical Approaches 2
- Quality Improvement Strategies 4
- Specialization of Care 2
- Clinical Information Systems 25
- Transparency and Accountability 1
- Alert fatigue 2
- Device-related Complications 1
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 2
- Failure to rescue 1
- Identification Errors 2
- Medical Complications 1
- Medication Safety 10
- Psychological and Social Complications 4
- Family Members and Caregivers 3
- Health Care Executives and Administrators 14
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Information Professionals
Search results for "Information Professionals"
- Information Professionals
Ross C. STAT. May 13, 2019.
Nuisance alarms, interruptions, and insufficient staff availability can hinder effective monitoring and response to acute patient deterioration. This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence to improve clinician response to alarms by proactively identifying hospitalized patients at the highest risk for heart failure to trigger emergency response teams when their condition rapidly declines.
Journal Article > Study
Shen C, Nguyen M, Gregor A, Isaza G, Beattie A. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
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.
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
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.
Parikh R. MIT Technol Rev. October 23, 2018.
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making in health care. This magazine article explains how artificial intelligence presents clinicians with an opportunity to improve practice by reducing cognitive load when determining appropriate diagnoses and treatment decisions.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
Journal Article > Study
Patient and consumer safety risks when using conversational assistants for medical information: an observational study of Siri, Alexa, and Google Assistant.
Bickmore TW, Trinh H, Olafsson S, et al. J Med Internet Res. 2018;20:e11510.
Experts have raised safety concerns for patients seeking medical information over the Internet. This study examined whether a conversational assistant such as Siri, Alexa, or Google Assistant would provide accurate information in response to a medical question. Lay participants queried a randomly assigned conversational assistant about their own health-related question and standardized questions relating to medication use and recognition of symptoms. Conversational assistants were unable to answer the majority of questions. Among the answered questions, a significant proportion of suggested actions (29%) could lead to harm. The authors conclude that conversational assistants are neither safe nor effective in providing actionable medical information.
Journal Article > Study
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.
Journal Article > Review
Consumer mobile apps for potential drug–drug interaction check: systematic review and content analysis using the Mobile App Rating Scale (MARS).
Kim BY, Sharafoddini A, Tran N, Wen EY, Lee J. JMIR Mhealth Uhealth. 2018;6:e74.
Patients are powerful allies in improving medication safety. This study found that available mobile applications that enable patients to check for drug–drug interactions are of moderate quality and low cost. They did not assess efficacy. An Annual Perspective examined other technological innovations for engaging patients in safety.
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.
Perspectives on Safety > Perspective
with commentary by Ronen Rozenblum, MD, MPH, and David Bates, MD, MS, Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017
This piece explores how patient-facing technologies can enable patients to be more responsible for their care and improve the way clinicians practice.
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4.
Over-reliance on technology can contribute to error due to user complacency. Reviewing how the tendency to trust in the correctness of information from technology can diminish human decision-making, this newsletter article offers strategies to address the problem including training clinicians to assess the reliability of the technology with monitoring and verification activities.
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.
Web Resource > Multi-use Website
Silverspring, MD: US Food and Drug Administration.
This Web site provides access to large publicly available datasets for adverse drug events to enable developers, researchers, and consumers to use this information when designing medication safety improvement plans or projects. Planned updates to this site include data on recalls and product documentation.