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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.

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 > 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.

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 > 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

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.

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.

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

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

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.

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

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

Prescription errors related to the use of computerized provider order-entry system for pediatric patients.

Alhanout K, Bun SS, Retornaz K, Chiche L, Colombini N. Int J Med Inform. 2017;103:15-19.

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.

Journal Article > Study

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

Quist AJL, Hickman TT, Amato MG, et al. Am J Health Syst Pharm. 2017;74:499-509.

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.

Journal Article > Study

Automated detection of look-alike/sound-alike medication errors.

Rash-Foanio C, Galanter W, Bryson M, et al. Am J Health Syst Pharm. 2017;74:521-527.

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.

Journal Article > Study

Association between elements of electronic health record systems and the weekend effect in urgent general surgery.

Kothari AN, Brownlee SA, Blackwell RH, et al. JAMA Surg. 2017;152:602-603.

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.

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