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Search results for "Information Professionals"

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Press Release/Announcement

AHRQ announces interest in research on health IT safety.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.

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.

Journal Article > Commentary

The promise of big data: improving patient safety and nursing practice.

Linnen D. Nursing. May 2016;46:28-34.

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.

Journal Article > Review

State-of-the-art usage of simulation in anesthesia: skills and teamwork.

Krage R, Erwteman M. Curr Opin Anaesthesiol. 2015;28:727-734.

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.

Journal Article > Study

Can social media be used as a hospital quality improvement tool?

Lagu T, Goff SL, Craft B, et al. J Hosp Med. 2016;11:52-55.

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.

Journal Article > Commentary

Measuring and improving patient safety through health information technology: the Health IT Safety Framework.

Singh H, Sittig DF. BMJ Qual Saf. 2016;25:226-232.

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.

Audiovisual > Audiovisual Presentation

Health IT Webinar Series.

Office of the National Coordinator for Health Information Technology and RTI International. December 2014–September 2015.

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.

Journal Article > Review

Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis.

Berdot S, Roudot M, Schramm C, Katsahian S, Durieux P, Sabatier B. Int J Nurs Stud. 2016;53:342-350.

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.

Journal Article > Study

Reflecting on diagnostic errors: taking a second look is not enough.

Monteiro SD, Sherbino J, Patel A, Mazzetti I, Norman GR, Howey E. J Gen Intern Med. 2015;30:1270-1274.

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.

Newspaper/Magazine Article

Draft Guidelines for the Safe Communication of Electronic Medication Information.

Institute for Safe Medication Practices. 2015;2;1-3,6.

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.

Journal Article > Commentary

Health information exchange in emergency medicine.

Shapiro JS, Crowley D, Hoxhaj S, et al. Ann Emerg Med. 2016;67:216-226.

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.

Journal Article > Commentary

Technology, cognition and error.

Coiera E. BMJ Qual Saf. 2015;24:417-422.

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.

Journal Article > Review

An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains.

Johnston MJ, Paige JT, Aggarwal R, et al; Association for Surgical Education Simulation Committee. Am J Surg. 2016;211:214-225.

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.

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.

Web Resource > Government Resource

Patient Centered Medical Home Resource Center: Quality and Safety.

Rockville, MD: Agency for Healthcare Research and Quality.

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.

Journal Article > Study

Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.

Mull HJ, Rosen AK, Shimada SL, et al. EGEMS (Wash DC). 2015;3:1116.

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.

Journal Article > Study

Best practices: an electronic drug alert program to improve safety in an accountable care environment.

Griesbach S, Lustig A, Malsin L, Carley B, Westrich KD, Dubois RW. J Manag Care Spec Pharm. 2015;21:330-336.

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.

Journal Article > Study

The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.

Panesar RS, Albert B, Messina C, Parker M. Am J Med Qual. 2016;31:64-68.

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.

Journal Article > Study

Health information technology and hospital patient safety: a conceptual model to guide research.

Paez K, Roper RA, Andrews RM. Jt Comm J Qual Patient Saf. 2013;39:415-425.

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

Cases & Commentaries

A Picture Speaks 1000 Words

  • Web M&M

Robin R. Hemphill, MD, MPH; September 2013

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.

Journal Article > Study

Role of computerized physician order entry usability in the reduction of prescribing errors.

Peikari HR, Zakaria MS, Yasin NM, Shah MH, Elhissi A. Healthc Inform Res. 2013;19:93-101.

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.

Journal Article > Study

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. J Am Med Inform Assoc. 2013;20:e59-e66.

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.

Perspectives on Safety > Interview

In Conversation With…David C. Classen, MD, MS

Trigger Tools, May 2012

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.

Journal Article > Commentary

Functional safety of health information technology.

Chadwick L, Fallon EF, van der Putten WJ, Kirrane F. Health Informatics J. 2012;18:36-49.

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.

Book/Report

AMIA Annual Symposium Proceedings: 2011.

AMIA Annu Symp Proc. 2011;19-1667.

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

Journal Article > Review

A systematic review of the psychological literature on interruption and its patient safety implications.

  • Classic

Li SY, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.

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.

Journal Article > Study

Using FDA reports to inform a classification for health information technology safety problems.

Magrabi F, Ong MS, Runciman W, Coiera E. J Am Med Inform Assoc. 2012;19:45-53.

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.

Journal Article > Review

The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials.

McKibbon KA, Lokker C, Handler SM, et al. J Am Med Inform Assoc. 2012;19:22-30.

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.

Newspaper/Magazine Article

Drug shortages: a pharmacy informatics perspective.

Edillo PN. Pharm Purch Prod. April 2011;8:26.

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

Audiovisual > Audiovisual Presentation

TMIT Briefing Center.

Austin, TX: Texas Medical Institute of Technology [SafetyLeaders.org]; 2007.

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

Journal Article > Study

Errors and electronic prescribing: a controlled laboratory study to examine task complexity and interruption effects.

Magrabi F, Li SY, Day RO, Coiera E. J Am Med Inform Assoc. 2010;17:575-583.

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.

Journal Article > Study

Interruptions in a level one trauma center: a case study.

Brixey JJ, Tang Z, Robinson DJ, et al. Int J Med Inform. 2008;77:235-241.

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

Newspaper/Magazine Article

Under-mined.

Greene J. Hosp Health Netw. 2006 December;80:38-40, 42, 44, 1.

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

Journal Article > Study

Citation classics in patient safety research: an invitation to contribute to an online bibliography.

Lilford R, Stirling S, Maillard N. Qual Saf Health Care. 2006;15:311-313.

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.

Newspaper/Magazine Article

Trends influencing the cost of care and patient safety.

Clark R. Health Manage Tech. July 2006:18, 20-21.

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

Journal Article > Commentary

Information behavior in the context of improving patient safety.

MacIntosh-Murray A, Choo CW. J Am Soc Inf Sci Tech. 2005;56:1332-1345.

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.

Journal Article > Review

Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety.

Koshy R. Transfusion. 2005;45(suppl 4):189S-205S.

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.

Journal Article > Study

Improving end of life care: an information systems approach to reducing medical errors.

Tamang S, Kopec D, Shagas G, Levy K. Stud Health Technol Inform. 2005;114:93-104.

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.

Book/Report

Health Information Technology Leadership Panel: Final Report.

Falls Church, VA: The Lewin Group, Inc.; 2005.

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.

Journal Article > Commentary

Medical research and the Institutional Review Board: the librarian's role in human subject testing.

Robinson JG, Gehle JL. Ref Serv Rev. 2005;33:20-24.

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.

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

The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.

Porat T, Delaney B, Kostopoulou O. BMC Med Inform Decis Mak. 2017;17:79.

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.

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 > Study

Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review.

Stockton KR, Wickham ME, Lai S, et al. CMAJ Open. 2017;5:E345-E353.

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.

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.

Newspaper/Magazine Article

Deep learning is a black box, but health care won't mind.

Brouillette M. MIT Technol Rev. April 27, 2017.

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.

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.

Journal Article > Commentary

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices.

Rao G, Epner P, Bauer V, Solomonides A, Newman-Toker DE. Diagnosis. 2017;4:67-72.

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.

Journal Article > Study

A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites.

Adelman JS, Berger MA, Rai A, et al. J Am Med Inform Assoc. 2017 Apr 17; [Epub ahead of print].

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.

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