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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Ambulatory computerized prescribing and preventable adverse drug events.

Overhage JM, Gandhi TK, Hope C, et al. J Patient Saf. 2016;12:69-74.

Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.

Journal Article > Study

An observational study to evaluate the usability and intent to adopt an artificial intelligence–powered medication reconciliation tool.

Long J, Yuan MJ, Poonawala R. Interact J Med Res. 2016;5:e14.

This study describes the development of a tablet-based program that includes artificial intelligence elements for guiding patients through medication reconciliation. The researchers observed 10 patients using the tool and collected survey feedback on its usability and value from a small number of physicians, nurses, and patients.

Journal Article > Commentary

Toward a safer health care system: the critical need to improve measurement.

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Jha A, Pronovost PJ. JAMA. 2016;315:1831-1832.

In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.

Journal Article > Study

Can medical record reviewers reliably identify errors and adverse events in the ED?

Klasco RS, Wolfe RE, Lee T, et al. Am J Emerg Med. 2016;34:1043-1048.

Classic studies of the epidemiology of adverse events in hospitalized patients have identified safety issues using retrospective chart review combined with trigger tools. This study examined this methodology to detect adverse events in emergency department patients and found good agreement between independent clinical reviewers regarding the presence of errors and adverse events.

Journal Article > Study

Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.

According to this study, many adverse drug event reports submitted by drug manufacturers to the Food and Drug Administration were incomplete. The authors advocate for the FDA to update their reporting requirements and compliance policies.

Journal Article > Study

Electronic health record–related events in medical malpractice claims.

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Graber ML, Siegal D, Riah H, Johnston D, Kenyon K. J Patient Saf. 2015 Nov 6; [Epub ahead of print].

Although heath information technology (IT) has improved patient safety, studies have shown that implementing electronic health records can introduce new errors. This study examined closed malpractice claims related to health IT. Most cases occurred in ambulatory care settings, suggesting that current health IT may not be optimally designed to support safety in those settings. Cases involving medication errors, diagnostic errors, or treatment complications were almost equally prevalent, indicating that health IT vulnerabilities span multiple tasks and functions. Software design issues and implementation problems also played a role in these incidents. These findings emphasize the need to reexamine health information technologies and how they are implemented in health care systems to enhance safety. A recent PSNet perspective examined challenges in health IT implementation, and another perspective discussed the need for innovations in health IT usability.

Journal Article > Commentary

Computerised prescribing for safer medication ordering: still a work in progress.

Schiff GD, Hickman TT, Volk LA, Bates DW, Wright A. BMJ Qual Saf. 2016;25:315-319.

The unintended consequences related to implementation of health information technologies have been widely documented. In this commentary, the authors offer insights regarding a government-funded investigation of 10 computerized provider order entry systems, discuss weaknesses in these systems, and make recommendations to focus on designing around human factors, enhancing workflow, and improving reporting.

Journal Article > Study

Enhancing surgical safety using digital multimedia technology.

Dixon JL, Mukhopadhyay D, Hunt J, Jupiter D, Smythe WR, Papaconstantinou HT. Am J Surg. 2016;211:1095-1098.

In this study, researchers developed a system for surgical time-outs where scanning a patient's wristband launches a presentation on the operating room monitor, which includes a video of the patient stating his or her name, date of birth, surgical procedure, and operative laterality. Although these took longer than standard timeouts (79 seconds versus 49 seconds), 87% of operating room personnel preferred the digital version, and performance of key safety elements significantly improved.

Journal Article > Study

Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.

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Lacson R, O'Connor SD, Sahni VA, et al. BMJ Qual Saf. 2016;25:518-524.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Web Resource > Course Material/Curriculum

TeamSTEPPS 2.0 Core Curriculum.

Rockville, MD: Agency for Healthcare Research and Quality; September 2015.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.

Journal Article > Study

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.

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Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. J Clin Oncol. 2015;33:3560-3567.

Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.

Journal Article > Study

Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.

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Rajaram R, Chung JW, Kinnier CV, et al. JAMA. 2015;314:375-383.

Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare and Medicaid Services reduces payments to hospitals with the highest rates of these conditions. This analysis sought to assess the association between measures of hospital quality, such as accreditation, and penalties for HACs. Researchers found that accredited hospitals were more likely to incur HAC penalties. Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients. These results add weight to concerns about unintended consequences of pay-for-performance programs leading to widening health disparities and selective treatment, or "cherry-picking" of healthier patients. A related editorial co-authored by two United States Senators calls for including socioeconomic status in the HAC penalty formula.

Journal Article > Study

Safety incidents in the primary care office setting.

Rees P, Edwards A, Panesar S, et al. Pediatrics. 2015;135:1027-1035.

Patient safety in outpatient settings is a growing concern. In this analysis of voluntarily reported safety events from the United Kingdom, researchers identified serious risks for children cared for in outpatient family medicine settings. Medication management, diagnostic errors, and errors in the referral process contributed significantly to patient harm, echoing prior studies about outpatient safety. The authors call for implementation of safety practices such as barcode medication administration, clinical decision support software, and electronic referral tracking, all of which remain incompletely implemented in ambulatory care. Given the known under-reporting of adverse events, this report likely underestimates the frequency of patient safety problems in this outpatient setting and emphasizes the need for active safety monitoring.

Journal Article > Study

Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors.

Smith KJ, Handler SM, Kapoor WN, Martich GD, Reddy VK, Clark S. Am J Med Qual. 2016;31:315-322.

Medication inconsistencies are common at hospital discharge. This study found that computerized discharge medication reconciliation, combined with automatic communication of the reconciled medication list to the patient's primary care physician, reduced discharge medication errors.

Journal Article > Study

Elucidating reasons for resident underutilization of electronic adverse event reporting.

Hatoun J, Suen W, Liu C, et al. Am J Med Qual. 2016;31:308-314.

This survey study found that most resident physicians did not use incident reporting systems for adverse events in which they were involved, often because they did not know what or how to report. These results highlight the shortcomings of voluntary reporting for patient safety.

Book/Report

Patient Safety Culture: Theory, Methods and Application.

Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.

This publication covers patient safety culture including its background in high-risk industries, key concepts involved such as behavior change, measurement and assessment processes, and lessons learned from application and practice.

Journal Article > Study

Health care–associated infections among critically ill children in the US, 2007–2012.

Patrick SW, Kawai AT, Kleinman K, et al. Pediatrics. 2014;134:705-712.

This large cohort study of 174 hospitals examined rates of central line–associated bloodstream infections (CLABSIs), ventilator-associated pneumonias, and catheter-associated urinary tract infections in neonatal and pediatric intensive care units (ICUs) across the United States. Between 2007 and 2012, there were remarkable reductions in these hospital-acquired infections among critically ill infants and children. In pediatric ICUs, CLABSIs plummeted from about 4.7 to 1.0 per 1000 central-line days, while ventilator-associated pneumonias dropped from 1.9 to 0.7 per 1000 ventilator-days. The trends were similar in neonatal ICUs. The authors estimate that the decrease in CLABSI rates alone not only enhanced patient safety but also saved $131 million for these hospitals during the study period. A recent AHRQ WebM&M perspective focused on hospital infection prevention programs.

Book/Report

Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer.

Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.

This book provides information about utilizing safety science and disseminating published evidence, staff knowledge, and other data to enable safety improvement and organizational learning from error.

Newspaper/Magazine Article

Medication administration errors in hospitals—challenges and recommendations for their measurement.

McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.

Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.

Book/Report

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309293099.

Cancer patients are particularly vulnerable to preventable errors in both inpatient and outpatient settings, as their care involves exposure to high-risk medications and requires closely coordinated care. Seen in that light, this Institute of Medicine report, which bluntly concludes that the current system of cancer care is untenable, is particularly concerning. The report highlights numerous deficiencies in the current system, such as insufficient compliance with evidence-based guidelines, high rates of medication errors, and failure to incorporate patient preferences into advanced care planning. To reshape how cancer care is delivered, the report recommends leveraging information technology to augment care coordination and real-time analysis of treatment data, better end-of-life planning, and improving communication with patients and families around prognosis and the risks and benefits of treatments. Multiple AHRQ WebM&M commentaries discuss safety issues in oncology patients, including a case of a chemotherapy medication error detected by the patient himself and a near-fatal error ascribed in part to poorly coordinated care.

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