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Search results for "Forcing Functions"

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Journal Article > Review

Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review.

Powers EM, Shiffman RN, Melnick ER, Hickner A, Sharifi M. J Am Med Inform Assoc. 2018;25:1556-1566.

Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.

Journal Article > Study

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors.

Scott GPT, Shah P, Wyatt JC, Makubate B, Cross FW. J Am Med Inform Assoc. 2011;18:789-798.

This study found that modal prescribing alerts—warnings that required a response from physicians, akin to forcing functions—were significantly more effective at preventing prescribing errors than alerts that could simply be ignored.

Journal Article > Study

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

A quality improvement process that included forcing functions resulted in significantly improved adherence to the Universal Protocol for prevention of wrong-site procedures.

Journal Article > Commentary

Checklists to reduce diagnostic errors.

Ely JW, Graber ML, Croskerry P. Acad Med. 2011;86:307-313.

Diagnostic errors are rapidly gaining attention as the next frontier in patient safety, driven by studies of their incidence in malpractice claims and autopsy reports. On the other hand, checklists have become popularized in health care as a tool to promote safe practices. This commentary explores the application of checklists to the diagnostic process. The authors suggest three types of checklists: a general one that prompts providers to optimize their cognitive approach, a differential diagnosis checklist to ensure correct diagnoses are considered, and a checklist of common pitfalls and cognitive forcing functions to improve evaluation of certain diseases. Specific examples of checklists are provided with a discussion of future directions to study their adoption and impact. A past AHRQ WebM&M perspective and interview discussed diagnostic errors in medicine.

Journal Article > Commentary

Mistake-proofing healthcare: why stopping processes may be a good start.

Grout JR, Toussaint JS. Bus Horiz. 2010;53:149-156.

This commentary describes two concepts grounded in lean manufacturing and human factors science—stopping the line and the forcing function. The authors present methods to implement these strategies to drive improvement and reduce error in health care.

Journal Article > Commentary

Use of the common gas outlet for supplementary oxygen during Caesarean section.

Edsell ME, Erasmus PD. Anaesthesia. 2005;60:1152-1153.

The authors respond to reports of problems with common gas outlets and describe a forcing function put in place at their hospital to minimize such incidents. For a detailed discussion of a very similar case, in which a patient with respiratory distress received compressed air instead of high-flow oxygen, see the AHRQ WebM&M commentary by Dr. David Gaba.

Perspectives on Safety > Perspective

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005

A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...

Cases & Commentaries

The Forgotten Med

  • Web M&M

Russ Cucina, MD, MS; April 2005

Thinking that the patient's glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic.

Cases & Commentaries

Around the Block

  • Web M&M

Tracy Minichiello, MD; March 2005

Despite a box on the admission form warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both, and becomes permanently paralyzed.

Journal Article > Study

Randomized controlled evaluation of an insulin pen storage policy.

Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.

This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.

Cases & Commentaries

The Hidden Harms of Hand Sanitizer

  • Web M&M

Stephen Stewart, MBChB, PhD; July 2017

Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

  • Classic

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017;26:734-742.

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Study

Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet.

Harada S, Suzuki A, Nishida S, et al. J Eval Clin Pract. 2017;23:582-585.

Insulin is known to be a high-risk medication. This pre–post study found that introduction of a standardized sliding scale insulin order led to decreased rates of insulin prescribing errors. However, the incidence of hyperglycemia or hypoglycemia did not change. This study demonstrates how standardization can support patient safety.

Journal Article > Study

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.

Journal Article > Study

More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes.

Lohmann K, Gartner D, Kurze R, et al. J Clin Pharm Ther. 2015;40:220-225.

Crushing pills or capsules is sometimes necessary when a patient is not capable of swallowing normally, but this can also be a source of medication errors. This study, conducted in a university hospital in Germany, demonstrated a significant reduction in inappropriate crushing of medications after an intensive educational program.

Journal Article > Study

Intercepting wrong-patient orders in a computerized provider order entry system.

Green RA, Hripcsak G, Salmasian H, et al. Ann Emerg Med. 2015;65:679-686.

While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

Journal Article > Review

Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU?

Weiss CH, Wunderink RG. Curr Opin Crit Care. 2013;19:448-452

This review evaluates the use of checklists coupled with forcing functions in the intensive care unit as a strategy to enhance appropriate antibiotic use.

Audiovisual > Audiovisual Presentation

July 2011 Author in the Room Teleconference.

Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.

Featuring an discussion with the author of a recent JAMA article, this archived webinar explored systemic causes for delays in test follow-up and offered strategies to address them.

Journal Article > Study

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.

Hard stop alerts within computerized provider order entry (CPOE) systems are intended to avert serious medication errors by preventing prescribing of contraindicated medications. This study investigated whether data from a CPOE system could be used to identify individual physicians who commit more frequent prescribing errors. However, the study found that trainee physicians who committed errors prompting hard stop alerts were not more likely to commit less serious prescribing errors, nor did they appear to ignore prescribing warnings more frequently. Although objective performance data would help identify doctors who frequently make prescribing errors, this study's results indicate that triggering of CPOE alerts is not a reliable measure.

Journal Article > Study

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

  • Classic

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

Computerized provider order entry (CPOE) systems prevent prescribing errors by warning clinicians about medication interactions or contraindications. However, extensive research has shown that clinicians ignore many warnings, especially those perceived as clinically inconsequential. In this randomized trial, investigators created a "hard stop" warning that essentially prevented co-prescribing of warfarin and trimethoprim-sulfamethoxazole (a combination that exposes patients to severe bleeding risks). Although the hard stop was much more successful than a less stringent warning at preventing co-prescribing, the trial was stopped and the warning abandoned because several patients experienced delays in needed treatment with one of the drugs. The accompanying editorial by Dr. David Bates points out that this study vividly illustrates the unintended consequences of CPOE, a persistent issue that has slowed the pace of CPOE implementation.

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