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Search results for "Information Professionals"

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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.

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.

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

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.

Journal Article > Study

Performance of a trigger tool for identifying adverse events in oncology.

Lipitz-Snyderman A, Classen D, Pfister D, et al. J Oncol Pract. 2017;13:e223-e230.

Investigators developed and validated a trigger tool to identify a range of harms in cancer care. Although their final tool had only a modestly accurate positive predictive value, they advocate refining and automating the trigger approach to enhance the detection of adverse events in oncology.

Cases & Commentaries

Unexpected Drawbacks of Electronic Order Sets

  • Web M&M

John D. McGreevey III, MD; November 2016

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

Journal Article > Study

Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery.

Tarola CL, Quin JA, Haime ME, et al. JAMA Surg. 2016;151:1183-1186.

Communication breakdowns in the operating room are associated with preventable adverse events. This study examined the potential of a novel workflow management system—a computerized system which used voice recognition and built-in algorithms to ensure important procedural steps were undertaken appropriately—to improve patient safety. The system was able to detect when intraoperative tasks were being performed and successfully identified omitted steps as well.

Cases & Commentaries

Lapse in Antibiotics Leads to Sepsis

  • Web M&M

Mitchell Levy, MD; October 2016

Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.

Cases & Commentaries

Unintended Consequences of CPOE

  • Spotlight Case
  • CME/CEU
  • Web M&M

Robert L. Wears, MD, PhD; October 2016

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

Journal Article > Study

Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management.

Finn A, Bondarenka C, Edwards K, Hartwell R, Letton C, Perez A. J Oncol Pharm Pract. 2016 Aug 29; [Epub ahead of print].

Chemotherapy administration has a well known potential for errors. This pre–post study found that implementation of an electronic health record–facilitated, pharmacist-led, standardized ordering and monitoring program for oral chemotherapy led to better identification of prescribing errors. This research adds to the evidence for the role of pharmacists in making cancer care safer.

Journal Article > Review

Identifying patients with sepsis on the hospital wards.

Bhattacharjee P, Edelson DP, Churpek MM. Chest. 2017;151:898-907.

Undiagnosed sepsis can lead to serious patient harm. This review describes proactive methods of monitoring patients to augment detection and early treatment of sepsis. The authors discuss how this process has evolved over time and suggest that automated tools can aid in identifying and managing sepsis.

Journal Article > Study

Clinical decision support for early recognition of sepsis.

Amland RC, Hahn-Cover KE. Am J Med Qual. 2016;31:103-110.

Sepsis is a clinical condition that can be rapidly fatal, thus prompt recognition and treatment is critical. This multicenter retrospective study describes the performance of a cloud-based computerized decision support system aimed at identifying sepsis in patients before infection was suspected.

Cases & Commentaries

Hyperglycemia and Switching to Subcutaneous Insulin

  • Web M&M

Tosha Wetterneck, MD, MS; December 2015

Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.

Journal Article > Study

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.

  • Classic

Topaz M, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2016;23:601-608.

Alert fatigue is recognized as a barrier to patient safety and may particularly increase risks associated with medication prescribing. This study examined the frequency of manual overrides of alerts for medication allergies over a 10-year period. Clinicians were required to provide a reason for overriding the allergy alert. As with earlier studies, the rate of overrides was very high. Researchers determined that the alerts were irrelevant in more than half the cases. Providers also were more likely to override repeated alerts compared with new alerts. These results highlight the overuse of alerts in health care settings and the need to improve their use to effectively support patient safety.

Journal Article > Study

Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems.

Aziz MT, Ur-Rehman T, Qureshi S, Bukhari NI. HIM J. 2015;44:13-22.

This quality improvement study to enhance the safety of chemotherapy was conducted at a tertiary care hospital in Pakistan. Investigators found that standardized chemotherapy orders within a computerized provider order entry system were associated with fewer medication errors as well as improved dispensing efficiency compared with the older, paper-based order system.

Cases & Commentaries

The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy

  • Spotlight Case
  • CME/CEU
  • Web M&M

Jacob Reider, MD; October 2015

After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.

Journal Article > Study

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.

  • Classic

Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. J Clin Oncol. 2015;33:3560-3567.

Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.

Journal Article > Commentary

A piece of my mind. Writing the wrong.

Patel JJ. JAMA. 2015;314:671-672.

Despite the potential for electronic health record (EHR) systems to improve access to patient data, unintended consequences have emerged that can hinder information seeking. To highlight how EHRs can detract from patient–physician relationships, this commentary reveals insights from a physician who failed to notice a patient's respiratory failure and distress due to over-reliance on the EHR.

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