Search results for "Information Professionals"

This announcement highlights AHRQ funding opportunities to support continued research regarding the safe use and implementation of health information technology systems with a focus on usability, user interaction, human factors engineering, system monitoring, and performance.

Big data is gaining attention as a way to improve quality and safety. This commentary discusses how outcomes data can be applied to enhance safety of nursing care and reviews limitations to successfully using analytics, including insufficient interoperability and inadequate funding to design effective tools.

Simulation training is a common method to enhance technical and nontechnical skills in health care. This review discusses simulation training in anesthesia and emphasizes the importance of learning objectives and activity design to drive success in high- and low-fidelity programs.

Researchers in this study reviewed patient feedback posted on a hospital's Facebook page to determine whether social media may be a helpful mechanism for identifying patient safety and quality improvement issues. In this small sample of 37 respondents over a 3-week period, insights from social media comments did not seem to add much to the feedback already collected by more traditional methods, such as patient satisfaction surveys.

Health information technology (IT) has promise for improving safety, but processes to measure and monitor its specific effect are lacking. Drawing from sociotechnical approaches and continuous quality improvement, this commentary outlines a framework for tracking improvements associated with the use of health IT. The framework focuses on three areas: concerns unique to technology, problems with use and misuse of health IT, and the ability of health IT systems to identify a failure and prevent it from affecting the patient.

Health information technology (IT) is seen as an important facilitator of transparency in health care, despite problems associated with these systems. This series of 10 webinars highlighted topics and research associated with the goal of improving the use of health IT, a national plan for a new health IT infrastructure and how it would be implemented.

This meta-analysis examined the efficacy of interventions to improve the safety of medication administration. Researchers looked at studies that used training methods (e.g., simulation) and technology approaches (e.g., computerized physician order entry and automated medication dispensing systems). The authors conclude that more randomized or experimental trials are needed in order to characterize the effect of these interventions, although they acknowledge the increasing implementation of barcode medication administration as a safety strategy.

This medical education study found that self-reflection only minimally improved diagnostic accuracy among medical residents in a simulation setting. These results suggest that a more robust cognitive debiasing curriculum may be needed to enhance diagnostic decision making.

How electronic medication-related information is communicated presents unique challenges to safe medication administration. This newsletter article discusses the field review of a set of evidence-based guidelines to provide direction and ensure safe transmission of information contained in electronic systems.

Insufficient access to patient information in the emergency department can result in patient harm. This commentary explores health information exchange systems, which provide clinicians with access to patient health information across multiple sources to enable continuity of care, in emergency medicine and offers recommendations to enhance the sharing of data to augment patient safety.

Providers and policymakers have raised concerns about risks associated with health information technology (IT). This commentary spotlights the importance of considering human factors and cognition when designing health IT systems to understand how human–computer interaction can contribute to error.

Simulation has been explored as a way to improve teamwork, crisis management, and technical skills in surgery. This review analyzes the evidence base on surgical simulation and identifies areas of progress, including curricula development, training techniques, and feedback methods. However, there is still a lack of data confirming the impact of simulation interventions on patient outcomes.

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.

The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure that team-based, coordinated, system-oriented, and accessible care is provided to patients in their homes. This Web site offers resources to support the application of systems principles in PCMHs and engage primary care clinicians, practices, and patients in achieving safety goals.

Trigger tools have been shown to be an efficient way to screen for adverse events. This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient setting. Five of the triggers performed reasonably well for either detecting harm or leading to a change in care plan.

This study of a quality improvement initiative found that automated screening of prescribing data uncovered many potential adverse drug events. Prescribers were notified about these safety concerns, and almost 80% of these potential adverse drug events were resolved through prescription changes. The extent of patient harm which occurred or was averted was not reported. This work suggests that real-time data from electronic prescribing could be harnessed to improve patient safety, as others have suggested.

Use of a structured communication tool within an electronic medical record resulted in increased high-quality communication between nurses and physicians around critical patient events.

This study revealed major gaps in the available nationwide data describing health information technology features and usage.

Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.

Computerized provider order entry users felt that the usability of the system was the most important factor in its ability to prevent medication prescribing errors.

This ethnographic study used direct observations in 11 primary care clinics with an integrated electronic health record (EHR) to characterize the extent and types of workarounds used by clinicians and support staff. As with prior classic research, the investigators found several different types of paper- and computer-based workarounds, with most being used to aid memory, improve efficiency, or enhance provider awareness of specific clinical problems. For example, several instances of copying and pasting clinical information from note to note were observed, despite this practice being against the institution's policy. Workarounds are generally regarded as representing EHR design failures, but the authors argue that it is unrealistic to expect EHRs to completely obviate the need for paper-based cognitive aids. They advocate for incorporating data on common types of workarounds into human factors–based approaches to improving EHR usability.

One of the pioneers of the trigger tool methodology for detecting adverse events, Dr. Classen is Chief Medical information Officer at Pascal Metrics and Associate Professor of Medicine at the University of Utah.

Discussing how safety concepts from other high-risk domains can improve patient safety, this piece recommends that electrical system standards be applied to health information technology design and implementation.

This publication includes numerous articles discussing how health information technologies can improve patient safety.

Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.

This study reviewed nearly 900,000 reports from the FDA Manufacturer and User Facility Device Experience database (MAUDE) and identified 678 reports describing health information technology issues. Investigators uncovered problems with software functionality, system configuration, interface with devices, and network configuration as new categories to the existing classification system.

This systematic review identified 87 randomized controlled trials assessing the effect of information technology on various aspects of medication safety, including studies of computerized provider order entry. Although processes of care consistently improved, few studies demonstrated improvement in clinical outcomes.

This article describes the impact of medication shortages on health systems and discusses how to manage them.

This Web site provides a directory to audiovisual resources on a variety of patient safety topics.

Interruptions during the medication administration process have been linked to an increased risk of error. This simulation study investigated the effect of interruptions on medication prescribing errors, using a controlled experimental design during which physicians were interrupted while prescribing within a computerized provider order entry system. Interruptions did not result in an increase in prescribing errors, but did significantly increase the time needed to complete complex prescribing tasks. The investigators hypothesize that CPOE systems provide visual cues that may help providers resume interrupted tasks without increasing the potential for error.

The investigators shadowed emergency department nurses and physicians and identified the types of interruptions that occurred and what factors contributed to them.

This article describes some of the challenges in collecting, storing, coding, and sharing data to help inform patient safety work.

Drawing from Agency for Healthcare Research and Quality's (AHRQ) 2001 comprehensive patient safety literature analysis, the authors determined the most cited and influential patient safety papers.

The author discusses five aspects to consider in adopting perioperative information technologies: system integration, fault tolerance, accessibility, workflow support, and measurable results.

The authors present a case study exploring information exchange in a patient care unit and suggest roles that can support patient safety improvement through more effective information flow.

The author examines technological advances for improving safety, such as bar coding, computerized physician order entry, radiofrequency identification, smart cards, decision support systems, and information technology standardization, and shares several strategies for implementation.

The authors discuss and analyze preliminary results from two palliative care information systems. Results indicate that such models can be employed to improve end-of-life care and information sharing between palliative care clinicians.

Prepared by the Lewin Group for the Department of Health and Human Services, this 45-page report summarizes the argument for widespread adoption of information technology (IT) systems as a mechanism to improve health care quality. The panel highlights three key imperatives, which include making IT implementation a top priority, encouraging the federal government to leverage its position to drive adoption, and promoting collaboration in these efforts with private sector purchasers and organizations. The report offers several strategic recommendations and also provides background on health IT, the associated economics, and factors that affect and promote adoption.

The authors discuss their organization's response to a 2001 incident in which an incomplete bibliographic review played a role in the death of a research volunteer. They outline an initiative to involve librarians in evidentiary review for clinical trials to ensure the safety of research subjects.

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.

The recent National Academy of Medicine report on improving diagnosis cited the need for enhanced clinical decision support. This pre–post study used a simulation approach (standardized patients) to compare visits with and without use of a diagnostic clinical decision aid embedded in the electronic health record. The patients' visit satisfaction ratings did not differ in the visits with and without the decision support, although more patients in the decision support group noted that physicians focused more on the computer than the patient. The physicians reported high overall satisfaction with the decision tool, but they noted that it required inputting more clinical documentation during the visit, resulting in more time directed at the electronic health record. The authors conclude that the clinical decision support tool interface should be improved in order to facilitate adoption of real-time diagnostic support.

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.

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.

An accurate list of patient medications is a necessary precursor for safe medication use. One strategy to improve medication reconciliation is to provide a list of dispensed outpatient medications to inpatient clinicians upon hospital admission via an electronic medication reconciliation process. This retrospective chart review study compared a research pharmacist–generated gold standard medication list to the actual medications ordered during an admission after such a process was implemented. The study team identified medication discrepancies between the pharmacist-generated and admission-ordered medication lists and noted any inappropriately prescribed or continued medications. Medication errors were present in nearly half of the patient records; about 9% of errors were clinically important. The authors raise concerns that electronically prepopulated medication reconciliation forms may actually adversely impact medication safety. A previous WebM&M commentary discussed how to enhance accuracy of medication reconciliation.

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.

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.

Artificial intelligence can support diagnostic decision-making. This magazine article reports on the use of algorithms to identify dermatologic cancers and highlights progress toward achieving success with these tools.

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.

This commentary explores diagnosis of common conditions in primary care and highlights approaches for studying the process, such as practice variation and patterning. The authors suggest big data as a method to mine electronic medical records to identify the information needed to inform improvement.

Wrong-patient errors can occur during computerized provider order entry, particularly if ordering clinicians have more than one patient record open. Experts have recommended that health systems allow only a single patient record to be open at a time to prevent these errors. This national survey of electronic health record leaders examined whether health systems permit records for multiple patients to be open simultaneously for electronic ordering and documentation. Nearly 200 health systems responded to the survey, and respondents described widely differing practices. Among health systems where clinicians could open multiple patient records at a time, the common justification was to support efficiency. A significant proportion did impose a restriction of working on one patient record at a time, and a smaller group limited clinicians to working with two open patient records only. These results suggest that further study of the optimal number of open patient records is needed to balance safety and efficiency in completing electronic health record work.

Computerized provider order entry has been shown to decrease adverse drug events, but it can also introduce new medication errors. This retrospective study examined medication ordering errors intercepted by pharmacists for pediatric patients. As with prior studies in pediatrics, this investigation uncovered dosing errors associated with weight-based dosing, including calculation errors and missing weight information. The most common medication associated with errors was acetaminophen, which can cause severe harm if incorrectly dosed. The authors call for improving electronic health record prescribing interfaces, better user training, and enhancing communication among providers to prevent medication errors.

Evidence suggests that computerized provider order entry (CPOE) systems improve medication safety by mitigating prescribing errors. However, CPOE systems may contribute to errors when user-centered design is not taken into account. In this study, researchers standardized the assessment of 10 distinct inpatient and ambulatory CPOE systems across 6 health care institutions to determine how variation in drug name display may increase the risk of medication errors. Using test patient scenarios, they found significant variation in drug name display, including inconsistencies with regard to the display of brand and generic names. Providers could theoretically prescribe both the brand and generic drug, increasing the risk for patient harm. A recent Annual Perspective discussed the benefits and limitations of CPOE with regard to patient safety.

Look-alike and sound-alike medications increase the risk of adverse drug events. This retrospective study found that look-alike and sound-alike medications can be identified in an automated fashion by comparing a medication and its known look-alike and sound-alike medications to diagnostic codes at the point of computerized provider order entry. This is a promising strategy for preventing this type of prescribing error.

Electronic health records enhance patient safety, but they also have unintended consequences. This retrospective study found that hospitals with a single-source electronic health record were less likely to have hospital-acquired safety events compared to hospitals with multiple systems in place. These results suggest that safety gaps may arise at the interface of multiple electronic systems.

This statewide, retrospective cross-sectional study identified longer than expected length of stay for urgent surgical procedures on the weekend compared to weekdays. Hospitals with electronic operating room scheduling and electronic bed management systems were less likely to demonstrate the weekend effect. These results suggest that health information technology can be employed to mitigate the weekend effect.

Although advanced computing can assist in diagnosis, these systems are not routinely utilized. This commentary suggests a framework to develop diagnostic support technologies that capture physician knowledge to enhance diagnostic safety. The authors encourage drawing from crowdsourced data to guide improvements at a system level to address future practice and educational needs.

While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.

The unintended consequences associated with health information technologies for medication management are well documented. Drawing from 889 medication error reports submitted over a 6-month period, this analysis found that more than half of the recorded incidents were associated with computerized provider order entry. Staff reporting of medication errors and near misses is key to identifying trends and consequently developing system improvements to reduce risks of such incidents.

This retrospective study reviewed more than 47,000 overridden medication alerts and found that the vast majority of overrides were clinically appropriate and did not cause harm. From this sample, 7 adverse drug events were identified, and these events were more likely when the alerts were overridden in error. This study demonstrates the challenge of identifying clinically important alerts in a setting where alert fatigue is common.

Poor usability of electronic health records is a patient safety concern. This qualitative study found that usability policies from the Office of the National Coordinator for electronic health records are less prescriptive about testing final products and rely more on attestation, compared to the Food and Drug Administration's usability policies for medical devices or the Federal Aviation Administration's usability policies for avionics. The authors suggest that other agencies' usability policies could inform federal efforts to enhance electronic health record usability.

Although computerized provider order entry has been found to prevent some medication errors, simulation studies have also demonstrated that electronic prescribing platforms can introduce or fail to prevent medication errors. This retrospective electronic health record analysis examined medication orders that were canceled. Weekend and overnight orders were less likely to be voided than weekday or daytime orders. Pharmacist, nurse, and student orders were more likely to be canceled than physician orders. Comparing the clinician-provided reason for voiding an order with the more comprehensive information in the medical record, physicians found that clinicians' reported reasons for voiding orders were largely inaccurate. The authors suggest there is unrealized potential to characterize medication ordering errors using voided-order data.

Voluntary error reporting systems are an important part of safety improvement programs, but difficulty in analyzing error reports has limited their utility. This study described the development of a machine learning algorithm to analyze free-text data in incident reports. The algorithm proved to be accurate in classifying events when compared to manual review.

Trigger tools seek to identify adverse events by flagging cases for review based on a particular data point (the "trigger"). Investigators, working through a Patient Safety Organization, sought an alternative to the widely used Institute for Healthcare Improvement Global Trigger Tool, one that would require less time and fewer resources. They developed a single, automated trigger encompassing a multitude of possible harms that could be implemented in real time. The most common harm identified by the novel trigger tool was hypoglycemia. The authors note that their tool detected more adverse events than the AHRQ Patient Safety Indicators. An accompanying editorial lauds this study as a step forward in efforts to harness the electronic health records to enhance patient safety through data analysis.

Electronic health records have both safety benefits and unintended consequences. This analysis used data from the 2010–2013 Medicare Patient Safety Monitoring System to compare the incidence of in-hospital adverse events among hospitals that did and did not meet meaningful use requirements for health information technology (IT), according to the Healthcare Information Management Systems Society Analytics Database. Investigators found that hospitals that met meaningful use criteria also reported fewer adverse events. Although the study design does not establish a causal relationship between implementation of health IT and the decline in adverse events, the authors argue that these advances in health IT contributed to this patient safety improvement.

Lack of interoperabilty and user errors are safety concerns associated with the use of electronic health records (EHRs). This case report provides two examples of problems with order cancellations in EHRs due to ineffective interfacing of systems that led to gaps in care. The authors recommend that hospitals test new information technologies to help identify weaknesses and make the ordering process safer.

Although computerized provider order entry systems are widely implemented, a prior review suggests that their ability to reduce adverse drug events remains uncertain. Less is known about their impact on safety culture. Researchers administered a modified Safety Attitudes Questionnaire survey 6 weeks after the implementation of an electronic prescribing system across surgical services at one hospital and found a decline in safety culture.

E-prescribing is a key strategy to improve medication safety by addressing illegible prescriptions, order omissions, and dosage confusion. However, there have been unintended consequences such as the inability to discontinue medications ordered electronically. This commentary reviews problems associated with this unintended consequence and suggests that enabling electronic cancellation of prescriptions can help address the issue. A WebM&M commentary discussed a case involving an electronic prescribing error.

Incomplete clinical notes create potential for treatment errors. This webinar discussed voice-generated electronic records as a strategy to augment clinical documentation and highlight natural language processing technologies as a component of this strategy.

Although computerized provider order entry is known to reduce medication errors, previous research has demonstrated that electronic prescribing can introduce new medication safety risks. This observational qualitative study of electronic prescribing at six British hospitals included direct observation, interviews, and analysis of implementation documents. Investigators determined multiple unintended consequences of electronic prescribing, at every stage of use, and identified design flaws in electronic prescribing platforms. Suboptimal implementation of electronic prescribing, with partial functionality and insufficient training, increased risk of errors. Once electronic prescribing was in place, prescribers started using workarounds and relied too much on the prescribing platform. The authors call for design and organizational strategies to mitigate these safety concerns. A past WebM&M commentary described a medication error related to electronic prescribing.

Simulation has been adopted as a valuable teaching tool in health care. This commentary reviews mastery learning theory at the individual and system levels and suggests that it can be enhanced with simulation to engineer effective processes at the organizational level.

The use of scribes, nonclinical staff who aid clinicians by entering information into electronic health records (EHRs), has increased markedly in the past few years. This qualitative study used interviews with clinicians, administrators, and scribes to develop a sociotechnical framework for the role of scribes with relation to the EHR. A prior commentary suggested that scribes represent a workaround that may inhibit the development of more advanced and user-friendly EHRs.

Improving diagnosis in outpatient care is a patient safety priority. This simulation study evaluated the process of diagnosis in the primary care setting. Investigators contrasted physicians' diagnostic accuracy conducting a primary care visit in their usual manner versus using a clinical decision support tool. Each visit employed a standardized patient (an actor reporting symptoms consistent with a given diagnosis) and the visits with and without decision support were matched for complexity. The tool improved diagnostic accuracy significantly: 68% of visits using decision support reached the correct diagnosis versus 59% of usual care visits. The duration of visits and number of subspecialty consultations did not change with or without decision support. Physician participants rated the usability of the decision support tool favorably overall. These data suggest that decision support can be feasibly integrated into primary care to improve diagnostic accuracy.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.

Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.

Medication errors continue to occur despite implementation of computerized provider order entry and clinical decision support systems. This study sought to assess whether medication error alerts might have a greater impact on mitigating such errors if they were generated based on outlier detection screening. Researchers analyzed data from the electronic health records of 747,985 outpatients to identify outliers that might indicate a medication error. They then chose 300 charts from the 15,693 resulting alerts. The charts were reviewed using a coding system to evaluate the utility of the alerts generated. About 75% of the chart-reviewed alerts created by the screening system identified possible medication errors. The authors suggest that using this type of outlier detection screening to generate alerts might improve existing clinical decision support systems' ability to mitigate medication errors. A prior WebM&M commentary discussed an incident involving an electronic prescribing error.

Diabetes medications are known to be high risk for adverse drug events. This case study reviews several patient safety measures for electronic prescribing for diabetes in outpatient care. Researchers describe an adverse drug event involving electronic prescribing of insulin and detail how the incident could have been prevented. Electronic prescribing is not currently standardized and may require using a trade name for medications, which may lead to prescribing errors. Adoption of the medication naming conventions put forth by the National Library of Medicine's RxNorm would prevent this vulnerability. Similarly, standardizing electronic prescribing orders for high-risk medications like insulin may reduce the risk of erroneously choosing a long-acting instead of short-acting insulin formulation, which can have life-threatening consequences. The authors advocate for using Universal Medication Schedule instructions and providing language-concordant labels to patients to support safe medication self-administration. They suggest that real-time, bidirectional communication between prescribers and pharmacists may improve safe prescribing. The authors conclude that recommended safety practices are not uniformly implemented in clinical practice and advocate for implementation research to ensure medication safety for outpatients with diabetes.

Investigators developed and validated a trigger tool to identify a range of harms in cancer care. Although their final tool had only a modestly accurate positive predictive value, they advocate refining and automating the trigger approach to enhance the detection of adverse events in oncology.

The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.

Inadequate test result management is known to contribute to missed and delayed diagnosis. This Veterans Affairs study found that 0.17% of radiologic studies were not evaluated by radiologists. The study team identified several technical and process problems that contributed to these unread studies. They were able to address the issues to ensure all studies were read.

Despite the demonstrated success of technology in reducing medication errors, preventable adverse drug events remain a significant source of harm to patients. Researchers analyzed data on medication safety events in 2 ICUs at a medical center and found 1622 preventable adverse drug events among 624 patients. About one third of these events were related to electronic health record use, including duplicate orders.

Medication errors are common in the neonatal intensive care unit. This commentary outlines various strategies one teaching hospital has utilized to reduce risks of medication errors in this care setting, such as use of computerized provider order entry and smart pumps.

Enterprise risk management focuses on managing risk at the system rather than the unit or incident level. This commentary discusses an enterprise risk management framework to assess and address problems associated with implementing technology. The authors outline potential risks present at the time of purchasing the technology and during pre- and post-implementation phases.

Although health information technology can improve patient safety, it can also introduce risks. Researchers analyzed data from daily electronic health record safety huddles at one hospital. They concluded that such huddles may be a useful strategy to identify and mitigate concerns related to electronic health record safety.

This systematic review of studies describing safety problems associated with health information technology identified mostly qualitative data and case reports. The authors suggest that their framework, an information value chain which extends from the interaction with technology to the patient outcome, could be used to enhance the literature on health information technology and safety.

Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Weight-based medication dosing can lead to medication errors in pediatric patients. Investigators used a trigger tool to detect weight-entry errors in the electronic health record. They found that dosing errors are rare and are most likely to occur in urgent and emergent settings. These findings suggest that a weight-entry trigger tool can identify pediatric patients at risk for dosing errors.

Use of medication administration technologies can reduce transcription errors. This review examined computerized order entry systems, barcode medication administration systems, and other tools that can prevent medication transcription errors.

Computerized decision support and advanced computing are being used to augment various processes in health care, such as medication ordering and diagnosis. This magazine article reports on the accuracy of these systems and the potential role of artificial intelligence in supporting diagnostic decision making.

Health information technology has enhanced prescribers' ability to document the purpose of medications they order. This newsletter article reviews weaknesses in electronic prescribing systems and recommends incorporating indication-based prescribing as the "sixth right" of safe medication use. The piece highlights how making indication information available can help inform medication communication, selection, adherence, and reconciliation.

Given the dependence of clinical processes on health information technology (IT), potential risks resulting from inability to access those systems are a significant safety concern. This review discusses ways to protect against large-scale failures of health IT systems and categorizes the types of failures that can occur. The authors suggest that a culture of safety can facilitate learning and improvement across the industry.

This news article discusses findings of an annual consensus report identifying health care technology hazards likely to be associated with accidental patient harm. Key concerns highlighted include inadequate sterilization of reusable instruments and smart pump programming errors.

Medication administration technologies can help collect data to enhance processes and reduce medication errors. This commentary discusses how organizations are using clinical decision support systems to track problems and incorporating different data sets to prevent adverse drug events.

Health information technology has the potential to facilitate patient safety tasks. This study described the development of a mobile health application for patient safety managers to enable activities such as tracking of risk management processes and safety audits. Users who tested the application reported high satisfaction with the tool, though its efficacy in enhancing safety was not studied.

Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

Preventing readmission after hospital discharge remains a top national priority. This study showed that ambulatory electronic health record (EHR) adoption is associated with decreased admissions for certain conditions. However, the investigators did not find such a correlation with regard to readmissions. They suggest that improving interoperability between hospital and clinic EHRs is an important next step.

Requirements are needed to manage risks associated with health information technology systems. This final rule provides a framework for government review of technologies certified by the ONC Health IT Certification Program. The rule also covers certification guidance for testing laboratories. The regulations go into effect December 19, 2016.

Information technology approaches have been advocated as a means of preventing diagnostic error. This study compared the diagnostic accuracy of computerized symptom checkers (software programs that use diagnostic algorithms based on patients' self-reported symptoms to suggest diagnoses) with that of practicing physicians. Physicians consistently arrived at more accurate diagnoses across a variety of simulated cases.