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Search results for "Information Professionals"

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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.

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

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.

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

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 > 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

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.

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