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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 > 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

Electronic health record–related events in medical malpractice claims.

  • Classic

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.

  • Classic

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.

Journal Article > Study

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

  • Classic

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

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.

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.

Newspaper/Magazine Article

Overclocking the hospital.

Ho V, Patton S. CIO Asia. September 2006.

This article discusses computerized physician order entry implementation in US and Asian hospital systems and provides insight into selecting a system and achieving team commitment to the development process.

Tools/Toolkit > Government Resource

Prevention Quality Indicators Overview.

AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality.

The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators use hospital admissions data to screen for potential quality lapses on conditions that generally don't require hospitalization if managed effectively at the primary care level.

Newspaper/Magazine Article

How business intelligence can improve patient safety.

Wanless S, McManaway J. Business Intelligence Network. August 30, 2005.

This article illustrates how hospitals can use their own administrative and patient data to reduce hospital-acquired infections.

Journal Article > Study

Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis.

Luxenberg A, Chan B, Khanna R, Sarkar U. JAMA Intern Med. 2017 Jun 19; [Epub ahead of print].

Prior research suggests that text paging in the health care setting may not be the most effective mode of communication for promoting patient safety. Researchers analyzed 575 distinct text pages regarding 217 patients and found that the messages lacked standardization, often did not indicate the level of urgency, and were frequently unclear. A related commentary considers structured versus fluid communication in health care.

Journal Article > Study

Implications of electronic health record downtime: an analysis of patient safety event reports.

Larsen E, Fong A, Wernz C, Ratwani RM. J Am Med Inform Assoc. 2017 May 30; [Epub ahead of print].

When electronic health records are out of use, either for planned upgrades or because of unexpected malfunction, this downtime disrupts usual hospital workflow. This study conducted an automated text search to identify incident reports related to electronic record downtime and analyzed the selected reports. Electronic health record downtime led to issues with laboratory testing including specimen identification errors and delayed transmission of results. Medication administration errors were also prevalent during downtime. Researchers found that downtime could hinder patient identification and information availability, which may result in serious safety hazards. The authors advocate for development of more comprehensive downtime procedures to address safety concerns as well as more consistent adherence to existing procedures.

Journal Article > Study

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.

Walker AS, Mason A, Quan TP, et al. Lancet. 2017 May 9; [Epub ahead of print].

The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.

Journal Article

E-collection: Safety and Error Prevention in Health.

JMIR Publications. 2015–2017.

The increasing implementation of health information technology has introduced both benefits and challenges to patient safety. Articles in this series explore the impacts of technology on health care, including whether patient rating sites contribute to hospital supervision, the potential for mobile communication devices to increase clinician distraction, and the design and testing of mobile applications to support care.

Journal Article > Commentary

Introducing a new junior doctor electronic weekend handover on an orthopaedic ward.

Maroo S, Raj D. BMJ Qual Improv Rep. 2017;6:u212695.w5059.

Handoffs and weekend care are two error-prone elements of health care. This commentary describes a project that focused on shifting from a paper-based to an electronic handoff process to enhance handover reliability over the weekend. The authors explain how using plan-do-study-act cycles helped augment implementation of the new handoff process. A recent PSNet interview discussed the weekend effect in health care.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

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