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Search results for "Hospitals"

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Journal Article > Study

A prospective controlled trial of an electronic hand hygiene reminder system.

Ellison RT III, Barysauskas CM, Rundensteiner EA, Wang D, Barton B. Open Forum Infect Dis. 2015;2:ofv121.

Hand hygiene remains one of the most basic targets for enhancing patient safety. Poor hand hygiene compliance persists despite multiple global efforts, and a recent study showed handwashing rates are likely even lower when there is not a direct observer recording compliance. This prospective controlled trial in two medical intensive care units (ICUs) studied the effect of an electronic reminder system. An audible chime for each room entry and exit initially increased handwashing events in the test ICU, but this effect quickly declined, likely related to alert fatigue. In contrast, a combination of a chime and real-time computer monitor feedback of current hygiene compliance rates resulted in an increase that lasted throughout the study phase. Once the reminder system was turned off, compliance rates returned to the previous baseline. Overall hand hygiene compliance rates were quite low: recorded handwashing occurred in only about one-third of room entries or exits. A prior AHRQ WebM&M perspective reviewed innovations in promoting hand hygiene compliance.

Journal Article > Review

Systematic review of the effectiveness of strategies to encourage patients to remind healthcare professionals about their hand hygiene.

Davis R, Parand A, Pinto A, Buetow S. J Hosp Infect. 2015;89:141-162.

Hand hygiene is critical to prevention of health care–associated infections. Despite intensive efforts, hand hygiene is not practiced universally in clinical settings. This systematic review sought to evaluate the effectiveness of patient-focused interventions to enhance adherence to hand hygiene practices. Researchers examined studies aimed at encouraging patients to remind health care providers to wash their hands. Because of the limited number and quality of current studies, researchers were unable to draw firm conclusions. Encouragement from health care providers seemed to be an important predictor for success in empowering patients to speak up about hand hygiene concerns. The authors recommend conducting more methodologically rigorous studies in order to determine the impact of patient-focused initiatives to promote hand hygiene. A recent AHRQ WebM&M perspective discussed strategies to enhance hand hygiene compliance.

Journal Article > Commentary

ACOG Committee Opinion #546: tracking and reminder systems.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2012;120:1535-1537.

This revision of the 2010 committee statement describes important characteristics for tracking systems and patient reminders to prevent missed or delayed diagnoses.

Journal Article > Study

It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.

Grant AM, Hofmann DA. Psychol Sci. 2011;22:1494-1499.

This comparison of different methods for promoting hand hygiene found that patient-centered reminders were effective at improving hand hygiene rates.

Journal Article > Commentary

Introducing the patient safety professional: why, what, who, how, and where?

Saint S, Krein SL, Manojlovich M, Kowalski CP, Zawol D, Shojania KG. J Patient Saf. 2011;7:175-180.

Discussing hospital-acquired conditions and strategies for prevention, this commentary recommends assigning a hospital-based clinician to assess safety at the individual patient level.

Newspaper/Magazine Article

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.

Cases & Commentaries

Patient Safety and Adherence to Self-Administered Medications

  • Web M&M

Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD; July 2011

A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.

Journal Article > Study

Increasing patient safety event reporting in 2 intensive care units: A prospective interventional study.

Ilan R, Squires M, Panopoulos C, Day A. J Crit Care. 2011;26:e11-e18.

A multifaceted intervention resulted in increased voluntary reporting of safety incidents in two intensive care units.

Journal Article > Study

Mixed results in the safety performance of computerized physician order entry.

  • Classic

Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.

Computerized provider order entry (CPOE) has provided significant safety benefits in research studies, especially when combined with clinical decision support to prevent common prescribing errors. However, CPOE's "real-world" performance has been mixed, with high-profile studies documenting a variety of unintended consequences. This AHRQ-funded study used simulated patient records to evaluate the ability of eight commercial CPOE modules to prevent medication errors. The overall results were disappointing, as CPOE failed to prevent many medication errors—including fully half of potentially fatal errors, which are considered never events. The individual CPOE products varied significantly in their ability to detect potential errors. Some hospitals did achieve superior performance, which the authors ascribe to greater experience with CPOE and implementation of more advanced decision support tools. Another recent article found that reminders within CPOE systems resulted in only small improvements in adherence to recommended care processes. Taken together, these studies imply that CPOE implementation may not result in large immediate effects on safety and quality in typical practice settings.

Journal Article > Study

Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.

Okon TR, Lutz PS, Liang H. J Pain Symptom Manage. 2009;37:1039-1049.

A quality improvement intervention that focused on management of acute pain resulted in both improved pain relief for patients and a reduction in medication errors associated with opioid pain medications.

Newspaper/Magazine Article

CPOE: it don't come easy.

Anderson HJ. Health Data Manag. January 1, 2009;17:18.

Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors, a mere 8% of hospitals use the system and fewer implement it effectively, according to the Leapfrog Group CPOE evaluation tool.

Perspectives on Safety > Interview

In Conversation with…Sanjay Saint, MD, MPH

Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008

Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.

Journal Article > Study

Tiering drug–drug interaction alerts by severity increases compliance rates.

Paterno MD, Maviglia SM, Gorman PN, et al. J Am Med Inform Assoc. 2009;16:40-46.

Customizing drug interaction warnings within a computerized order entry system resulted in fewer clinicians overriding the warnings.

Journal Article > Study

Timely follow-up of abnormal outpatient test results: perceived barriers and impact on patient safety.

Moore C, Saigh O, Trikha A, Lin JJ. J Patient Saf. 2008;4:241-244.

Physicians reported dissatisfaction with their ability to follow up on test results in a timely fashion, with resident physicians frequently reporting an inability to check test results in less than 1 week. The need for standardized methods for following up test results in ambulatory care was noted in a prior study.

Journal Article > Study

Making patients safer: nurses' responses to patient safety alerts.

Lankshear A, Lowson K, Harden J, Lowson P, Saxby RC. J Adv Nurs. 2008;63:567-575.

This study demonstrated that simply designing "system" safeguards fails to prevent errors in subsequent monitoring and implementation. Investigators used three safety alerts, including latex allergy, as markers of how well these alerts were being adopted in practice by bedside nurses.

Journal Article > Study

Reducing medication prescribing errors in a teaching hospital.

Garbutt J, Milligan PE, McNaughton C, et al. Jt Comm J Qual Patient Saf. 2008;34:528-536.

An educational intervention reduced prescribing errors by surgical residents but not medical residents.

Journal Article > Study

Use of a computerized forcing function improves performance in ordering restraints.

Griffey RT, Wittels K, Gilboy N, McAfee AT. Ann Emerg Med. 2009;53:469-476.

Computerized reminders to renew orders for physical restraints were combined with a forcing function—denial of computer access until the order was completed—in this trial conducted in an emergency department. Although clinician ordering behavior improved, no significant improvement was found in the amount of time patients spent in restraints.

Journal Article > Study

The use of a CPOE log for the analysis of physicians' behavior when responding to drug-duplication reminders.

Long A-J, Chang P, Li Y-C, Chiu W-T. Int J Med Inform. 2008;77:499-506.

This study used a log file within a computerized physician order entry (CPOE) system to understand the role physician- and policy-related variables, as well as patient resistance, played in responding to electronic reminders about drug duplication orders.

Cases & Commentaries

On the Other Hand

  • Web M&M

Elizabeth A. Henneman, RN, PhD; May 2007

A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.

Newspaper/Magazine Article

Hospitals target risks of color wristbands.

Landro L. Wall Street Journal. April 4, 2007:D5. 

This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.

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