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Perspectives on Safety
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606
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Human Factors Engineering
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684
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Safety Target
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Medical Complications
21
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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 > 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
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.
