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Search results for "Hospitals"

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Journal Article > Study

Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital.

Guérin A, Tourel J, Delage E, et al. Drug Saf. 2015;38:729-736.

This pre-post study evaluated the impact of smart pump infusion devices on reported adverse drug events (ADEs) in an inpatient setting. Researchers observed an increase in ADEs immediately following implementation of the new devices, as has been previously seen after electronic health record implementation. Subsequently, ADEs returned to rates similar to before smart pump use. This lack of benefit from smart pumps indicates the need for human factors approaches to characterize the actual use of devices.

Journal Article > Study

Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge.

Mussman GM, Vossmeyer MT, Brady PW, Warrick DM, Simmons JM, White CM. J Hosp Med. 2015;10:574-580.

Every day the care of hospital patients is handed off from clinician to clinician, creating serious risks for patient safety. A comprehensive quality improvement program that standardized communication processes and introduced basic electronic health record messaging enhanced the rate of postdischarge verbal handoffs to primary care providers.

Journal Article > Review

A safe practice standard for barcode technology.

Leung AA, Denham CR, Gandhi TK, et al. J Patient Saf. 2015;11:89-99.

Barcode technology has been advocated as a strategy to reduce medication errors. This narrative review explored barcoding solutions applied in various care settings and found that they resulted in notable reductions of transcription, dispensing, and administration errors. The authors recommend standards for successful implementation of barcode technology systems.

Journal Article > Study

Acceptability and feasibility of the Leapfrog computerized physician order entry evaluation tool for hospitals outside the United States.

Cho I, Lee JH, Choi SK, Choi JW, Hwang H, Bates DW. Int J Med Inform. 2015;84:694-701.

Applying the Leapfrog computerized provider order entry evaluation tool to four hospitals in South Korea exposed many opportunities for improvement. Although initially there was concern that national differences in drug prescription patterns might make the tool, which was developed for practices in the United States, unreliable, researchers found sufficient overlap to successfully complete the evaluation.

Journal Article > Study

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

Murphy DR, Thomas EJ, Meyer AND, Singh H. Radiology. 2015;277:81-87.

Delays in follow-up of abnormal test results are known to contribute to delayed and missed diagnosis. Investigators developed and validated an electronic trigger to identify potential delays in follow-up of abnormal chest computed tomography scans. This study found that more than half of the flagged cases had a true diagnostic delay. This work should lead to prospective evaluation of trigger approaches to enhance test result follow-up.

Journal Article > Study

We thought we would be perfect: medication errors before and after the initiation of computerized physician order entry.

Schwartzberg D, Ivanovic S, Patel S, Burjonrappa SC. J Surg Res. 2015;198:108-114.

This pre-post study found an increase in medication prescribing errors following the introduction of computerized provider order entry. This work adds to the growing literature about unintended consequences of electronic prescribing, highlighting the need for real-time error detection.

Journal Article > Review

Nurses' use of computerized clinical guidelines to improve patient safety in hospitals.

Hovde B, Jensen KH, Alexander GL, Fossum M. West J Nurs Res. 2015;37:877-898.

Clinician use of clinical guidelines is known to be less than optimal. According to this review, evidence indicates that nurse utilization of computerized clinical guidelines resulted in care process improvements, but further research is needed to determine if there is a correlation between increased provider access to guidance and patient safety.

Journal Article > Commentary

Development of an instrument to measure the unintended consequences of EHRs.

Carrington JM, Gephart SM, Verran JA, Finley BA. West J Nurs Res. 2015;37:842-858.

Electronic health records (EHRs) can improve and hinder the safety of care delivery. This commentary describes how existing data was used to develop a tool to measure unintended consequences of EHRs, which can help inform enhancements to EHR implementation.

Journal Article > Review

A new, evidence-based estimate of patient harms associated with hospital care.

James JT. J Patient Saf. 2013;9:122-128.

The seminal 1999 Institute of Medicine study estimated that as many as 98,000 patients may die each year due to preventable errors, a number that has entered the popular lexicon. However, this study found that preventable adverse events may actually result in much more harm. Based on analysis of four studies using the Global Trigger Tool, the study concludes that between 210,000 and 400,000 patients experience harm contributing to their death each year. Although the accuracy of the Global Trigger Tool for assessing preventability of harm has been questioned, other studies have also concluded that the overall incidence of preventable adverse events has likely not improved over the past decade.

Journal Article > Study

Evaluating the accuracy of electronic pediatric drug dosing rules.

Kirkendall ES, Spooner SA, Logan JR. J Am Med Inform Assoc. 2014;21:e43-e49.

Comparing the accuracy of electronic dosing rules provided by a commercial vendor with traditional clinical dosing rules in pediatrics, this stimulation study found that the electronic rules were accurate only 55% of the time. This finding highlights the possible unintended consequences of health information technology (IT) on patient safety and underscores the specific challenge of pediatric medication prescribing. A recent AHRQ WebM&M commentary examines the complex issues around medication dosing for pediatric patients.

Journal Article > Study

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

Szekendi MK, Sullivan C, Bobb A, et al. Qual Saf Health Care. 2006;15:184-190.

This study demonstrated the effective use of an active surveillance methodology designed to improve on current systems that fail to capture events at the time of occurrence. Investigators evaluated more than 325 medical records that were identified based on electronic triggers to develop their method for reviewing adverse events in real time. The authors discuss the large percentage of preventable adverse events that were discovered along with some of the interventions designed to prevent their recurrence. They also discuss how an active surveillance process would improve on existing hospital-wide efforts to promote patient safety.

Journal Article > Study

Reducing warfarin medication interactions: an interrupted time series evaluation.

Feldstein AC, Smith DH, Perrin N, et al. Arch Intern Med. 2006;166:1009-1015.

The authors evaluated the effectiveness of computerized alerts in reducing co-prescribing of warfarin and interacting medications. They found that the alerts had a modest impact on minimizing this potentially dangerous behavior.

Award

22 California hospitals earn top status for outstanding patient safety & health care quality.

San Francisco, CA: The Leapfrog Group; May 2, 2006.

This news release announces that 22 California hospitals have been recognized for their achievements in addressing The Leapfrog Group's standards of quality and safety.

Journal Article > Commentary

Internally-developed online adverse drug reaction and medication error reporting systems.

Smith KM, Trapskin PJ, Empey PE, Hecht KA, Armitstead JA. Hosp Pharm. 2006;41:428-436.

The authors describe the development and use of an in-house, online reporting system.

Web Resource > Government Resource

National Comparative Audit of Blood Transfusion.

National Blood Service Hospitals.

This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.

Journal Article > Commentary

Reflecting on change.

Wagstaff R. Nurs Manag (Harrow). May 2006;13:12-17.

The author examines the behavioral aspects of managing change associated with the implementation of a new computerized patient admission information system.

Journal Article > Commentary

Safe use of cellular telephones in hospitals: fundamental principles and case studies.

Cohen T, Ellis WS, Morrissey JJ, Bakuzonis C, David Y, Paperman WD. J Healthc Inf Manag. Fall 2005;19:38-48.

After reviewing the literature and several case studies, the authors conclude that cell phones can be safely used in hospitals if steps are taken to avoid electromagnetic interference.

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.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Newspaper/Magazine Article

Study: clinicians copy and paste about half of text in EHR progress notes.

Landi H. Healthcare Informatics. June 1, 2017.

The use of copy and paste is a popular time-saving mechanism to update electronic medical documentation, but this practice can introduce risks. This news article reports on various resources that explore problems associated with the copying and pasting in electronic health records, including a recent study that highlighted how this practice can perpetuate incomplete or wrong information into patient records.

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