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Search results for "Information Professionals"

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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.

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.

Journal Article > Commentary

Challenges in patient safety improvement research in the era of electronic health records.

Russo E, Sittig DF, Murphy DR, Singh H. Healthc (Amst). 2016;4:285-290.

Using a case study on missed and delayed follow-up of test results, this commentary explores challenges and opportunities that data from electronic health records present for patient safety research. Key barriers to utilizing electronic health record data to inform improvement work include restricted access to data, difficulty interpreting data, and workforce issues.

Journal Article > Commentary

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

Robinson SN, Neyens DM, Diller T. Am J Med Qual. 2017;32:285-291.

There is a recognized challenge in developing true opportunities for improvement with incident reporting. Using a case study method, this commentary describes a tested incident assessment framework that employs charting mechanisms to monitor both harm and nonharm events that result in process or workflow changes to indicate reliability of care in real time.

Journal Article > Commentary

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

Singh H, Sittig DF. BMJ Qual Saf. 2015;24:103-110.

This commentary describes a three-element framework to enable study and evaluation of diagnostic errors. The model considers the sociotechnical process through which diagnosis happens, the external factors that influence the patient–clinician encounter, and the postdiagnosis patient outcomes to define measures.

Journal Article > Study

Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit.

Balasuriya L, Vyles D, Bakerman P, et al. J Patient Saf. 2014 Oct 31; [Epub ahead of print].

This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue.

Journal Article > Commentary

Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.

Upadhyay DK, Sittig DF, Singh H. Diagnosis (Berl). 2014;1:283.

Misdiagnosis and errors linked to electronic health records (EHRs) are common concerns in patient safety. This commentary examines these elements in the context of the first Ebola case in the United States to reveal weaknesses in emergency department care, disaster management, and diagnostic processes. The case analysis highlights challenges associated with forming diagnoses and the usability of EHRs as decision support tools.

Journal Article > Commentary

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports.

Ratwani RM, Fong A. J Am Med Inform Assoc. 2015;22:312-317.

This commentary describes the design and development of hospital-level and system-level dashboards representing data from patient safety event reporting systems as a way to reduce the burden of analyzing internal incident reports, increase awareness of adverse event trends, and enable utilization of the data to inform improvement.

Journal Article > Study

Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM.

Boyd AD, Yang YM, Li J, et al. J Am Med Inform Assoc. 2015;22:19-28.

Administrative data generated for billing purposes is often used as a means of detecting adverse events. This method is limited by the fact that the ICD-9 diagnosis coding system does not specifically define many common adverse events, and as a result AHRQ developed the Patient Safety Indicators (PSIs) to screen administrative data for this purpose. The updated ICD-10 coding system will be implemented nationwide in the United States in 2015. The Centers for Medicare and Medicaid Services has proposed translations of the PSIs for ICD-10, but this study found substantial inaccuracies when ICD-10-based administrative data was screened using these translations. For example, the PSI for pressure ulcers demonstrated a high false-negative rate, meaning that ICD-10 based data will likely under-report the true incidence of this never event. Other PSIs demonstrated the opposite problem—potential for over-reporting due to a high false-positive rate—and some PSIs have greater potential for variability in interpretation by coders due to the substantially larger number of diagnoses included in ICD-10 (a problem noted in a prior systematic review). The results of this study raise serious concerns about the validity of administrative data for measuring patient safety in the ICD-10 era.

Journal Article > Commentary

Adverse events in healthcare: learning from mistakes.

Rafter N, Hickey A, Condell S, et al. QJM. 2015;108:273-277.

This review discusses chart reviews, trigger tools, and voluntary reporting as approaches to monitor adverse events and explores how lack of a standard method to collect and analyze data can hinder progress in determining trends and learning from reported information.

Journal Article > Commentary

The ethical imperative to think about thinking.

Stark M, Fins JJ. Camb Q Healthc Ethics. 2014;23:386-396.

This commentary spotlights the importance of learning about cognitive science to understand and improve diagnostic reasoning in order to prevent errors. Underscoring limits of the Hippocratic Oath, the authors describe the ethical responsibility of individuals and organizations to augment clinical decision-making, judgment, and critical thinking skills as an integral component of professionalism.

Journal Article > Review

Interventions to reduce pediatric medication errors: a systematic review.

Rinke ML, Bundy DG, Velasquez CA, et al. Pediatrics. 2014;134:338-360.

Pediatric patients are at particularly high risk for medication errors. Numerous strategies have been suggested for decreasing this preventable harm, but few have been robustly tested. This systematic review sought to determine the effectiveness of interventions to reduce pediatric medication errors, though many limitations and gaps were identified in the current literature. For example, only 1% of studies were conducted at community hospitals, and only 11% were in ambulatory settings. Also, even though 41% of studies involved computerized provider order entry, a meta-analysis could not be performed due to inconsistent methodology between studies. The review did highlight several promising interventions that improved medication safety, including clinical decision support tools, provider education programs, and preprinted order sheets. An AHRQ WebM&M commentary emphasizes the high potential for weight-based medication errors in pediatrics and provides recommendations to help mitigate this risk.

Journal Article > Study

An analysis of electronic health record–related patient safety concerns.

  • Classic

Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. J Am Med Inform Assoc. 2014;21:1053-1059.

Health information technology is being rapidly utilized in the clinical environment, with recent data showing that most hospitals and clinics have implemented some form of electronic health record (EHR). In this context, this report from the Veterans Health Administration's Informatics Patient Safety Office is timely, as it uses a sociotechnical framework that takes into account both technical aspects and human factors engineering principles to analyze 100 safety incidents relating to the EHR. The authors found four categories of system flaws: mismatches between user needs and information displays, errors arising from software modification or updates, failures at the interface between the EHR and other clinical systems, and hidden dependencies within the system itself. Most of these issues were identified long after the EHR was implemented, highlighting the need for ongoing monitoring and optimization of EHRs to ensure their safety capabilities are being maximized. An error caused in part by lack of interoperability between two clinical information systems is discussed in a prior AHRQ WebM&M commentary.

Web Resource > Multi-use Website

OpenFDA.

Silverspring, MD: US Food and Drug Administration.

This Web site provides access to large publicly available datasets for adverse drug events to enable developers, researchers, and consumers to use this information when designing medication safety improvement plans or projects. Planned updates to this site include data on recalls and product documentation.

Newspaper/Magazine Article

Medication administration errors in hospitals—challenges and recommendations for their measurement.

McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.

Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.

Perspectives on Safety > Interview

In Conversation With… Enrico Coiera, MB, BS, PhD

Interruptions and Distractions in Health Care, February 2014

Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.

Journal Article > Study

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.

  • Classic

Cresswell KM, Bates DW, Williams R, et al. J Am Med Inform Assoc. 2014;21:e194-e202.

The introduction of computerized provider order entry (CPOE) systems has led to many readily apparent advantages, as well as some serious unintended consequences. This study investigated the effects of introducing a commercial CPOE system with very basic decision support at one hospital and a robust clinical decision support system at another. Both hospitals had used these programs for at least 2 years prior to the study. Negligible overall differences in the consequences were observed between the two systems. Although individuals reported that the computer system seemed to save time for some tasks, most users felt an overall increase in their workloads. Major barriers included the amount of time required to log in and inadequate computer infrastructure in clinical work environments. Clinicians demonstrated an array of workarounds to enhance efficiency, which often undercut patient safety. A previous AHRQ WebM&M interview discussed the unintended consequences of technology.

Journal Article > Commentary

From heroism to safe design: leveraging technology.

Pronovost PJ, Bo-Linn GW, Sapirstein A. Anesthesiology. 2014;120:526-529.

This commentary reviews problems related to health IT, including inadequate interoperability and poor usability. The authors highlight transdisciplinary engagement in implementation as a strategy to ensure utility of health IT interventions.

Journal Article > Study

Clinical benefits of electronic health record use: national findings.

King J, Patel V, Jamoom EW, Furukawa MF. Health Serv Res. 2014;49:392-404.

This survey of more than 1700 physicians in ambulatory practice found generally positive perceptions of electronic health records (EHRs), with approximately 80% reporting that EHRs enhanced the overall quality of care for patients. Respondents also noted safety benefits, with two-thirds reporting that the EHR alerted them to a potential medication error.

Grant > Government Resource

Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (R21).

Rockville, MD: Agency for Healthcare Research and Quality; November 13, 2013. Funding Opportunity Announcement No. PA-14-001.

This grant opportunity will fund projects to research and develop the evidence around tracking the effect of health information technology on care quality.

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