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Search results for "Information Professionals"

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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.

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.

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.

Journal Article > Commentary

Responsible e-prescribing needs e-discontinuation.

Fischer S, Rose A. JAMA. 2017;317:469-470.

E-prescribing is a key strategy to improve medication safety by addressing illegible prescriptions, order omissions, and dosage confusion. However, there have been unintended consequences such as the inability to discontinue medications ordered electronically. This commentary reviews problems associated with this unintended consequence and suggests that enabling electronic cancellation of prescriptions can help address the issue. A WebM&M commentary discussed a case involving an electronic prescribing error.

Book/Report

Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use.

Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.

Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.

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 > Study

Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.

Pontefract SK, Hodson J, Marriott JF, Redwood S, Coleman JJ. PLoS One. 2016;11:e0160075.

Although electronic health records (EHRs) with computerized provider order entry are known to improve medication safety, experts have raised concerns that EHRs adversely affect interprofessional communication by reducing personal interactions among providers. This study examined unidirectional computerized messages from pharmacists and physicians within the EHR. Investigators found that less than half of messages from pharmacists were acknowledged by the prescribing physicians. Among the messages in which pharmacists requested a specific action, physicians completed the action about one-third of the time. Messages were more likely to be acknowledged and acted upon when pharmacists and physicians had an existing working relationship. The authors suggest that EHRs should be better designed to foster interprofessional collaboration. A PSNet perspective highlighted the role of pharmacists in interprofessional care and safety.

Newspaper/Magazine Article

Do not let "Depo-" medications be a depot for mistakes.

ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.

Confusion due to look-alike and sound-alike medications are known to contribute to medication errors. Describing errors associated with a certain medication naming convention, this newsletter article offers recommendations to reduce risks related to these drugs, including labeling clarifications, storing medications separately, barcode scanning, and staff education.

Journal Article > Study

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

Her QL, Amato MG, Seger DL, et al. J Am Med Inform Assoc. 2016;23:924-933.

Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.

Journal Article > Study

Analysis of prescribers' notes in electronic prescriptions in ambulatory practice.

  • Classic

Dhavle AA, Yang Y, Rupp MT, Singh H, Ward-Charlerie S, Ruiz J. JAMA Intern Med. 2016;176:463-470.

Many ambulatory practices have recently introduced electronic prescribing, which has the potential to improve medication safety. In this large cross-sectional study, researchers analyzed more than 26,000 electronic prescriptions that included free-text notes sent to community pharmacies. Two-thirds of free-text notes contained inappropriate content, despite the availability of a standard data field. Nearly 1 in 5 of these notes included conflicting administration instructions from the designated structured field, creating an important source of potential medication errors. In addition, approximately 5% of notes contained irrelevant information, which may distract or confuse pharmacy staff. The authors outline recommended solutions based on the information most commonly included in prescription free-text notes.

Journal Article > Commentary

Automatic errors: a case series on the errors inherent in electronic prescribing.

Lourenco LM, Bursua A, Groo VL. J Gen Intern Med. 2016;31:808-811.

Inadvertent dispensing of discontinued medications can result in patient harm. Examining incidents involving such medication errors, this commentary spotlights the need for enhanced electronic medical records to reduce risks related to discontinuation orders.

Journal Article > Commentary

The problem with medication reconciliation.

Pevnick JM, Shane R, Schnipper JL. BMJ Qual Saf. 2016;25:726-730.

Medication reconciliation has demonstrated safety improvement in both inpatient and ambulatory settings. This commentary discusses barriers to reliably implementing medication reconciliation and attributes those challenges to the complexity of health care delivery and the costs involved in developing and sustaining a working process.

Journal Article > Study

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors.

Pevnick JM, Palmer KA, Shane R, et al. J Am Med Inform Assoc. 2016;23:942-950.

This study measured the potential of using Surescripts electronic pharmacy claims data to prevent admission medication history errors among a sample of 70 older patients on complex medication regimens. Accessing this database would likely have prevented at least 35% of these medication reconciliation errors and nearly half of the most severe errors.

Journal Article > Study

Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy.

Suzuki S, Chan A, Nomura H, Johnson PE, Endo K, Saito S. J Oncol Pharm Pract. 2017;23:18-25.

Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.

Perspectives on Safety > Interview

In Conversation With… Lorri Zipperer, MA

Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015

Ms. Zipperer was a founding staff member of the National Patient Safety Foundation as their information projects manager and has also been Cybrarian for AHRQ Patient Safety Network since its inception. We spoke with her about the role of librarians in patient safety.

Journal Article > Study

Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.

Idemoto LM, Williams BL, Ching JM, Blackmore CC. Am J Health Syst Pharm. 2015;72:1481-1488.

This study examined the effect of a custom alert intended to reduce medication-timing errors associated with introduction of computerized provider order entry, which can lead to too-frequent or missed doses of medications. Using a rigorous interrupted time-series design, researchers found fewer medication-timing errors after implementation of this alert. This work demonstrates how custom alerts developed by clinicians can harness the electronic health record to improve safety.

Journal Article > Study

Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.

Cochran GL, Barrett RS, Horn SD. Am J Health Syst Pharm. 2016;73:1167-1173.

Medication errors are a well-recognized source of preventable patient harm and result from mistakes made during medication prescribing, transcribing, dispensing, and administration processes. This study looked at the impact of several factors on reducing medication errors in critical access hospitals. Investigators found that dispensing by an onsite pharmacist and the use of barcode technology for administration were both associated with a statistically significant reduction in medication errors.

Journal Article > Study

Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding.

MacKay M, Anderson C, Boehme S, Cash J, Zobell J. Nutr Clin Pract. 2016;31:195-206.

Computerized provider order entry with clinical decision support can be a powerful tool for alerting clinicians to potential prescribing errors. In this study at a large pediatric institution, implementation of a computerized provider order entry program for total parenteral nutrition resulted in a reduction in prescribing errors.

Journal Article > Commentary

Preparing challenging medications for barcode scanning.

Waxlax TJ. Am J Health Syst Pharm. 2015;72:1089-1090.

Barcode scanning can reduce medication administration errors, but certain packaging and dosage formulations require special attention to ensure the process improves safety. This commentary draws from examples such as preparation of insulin and use of ampules to illustrate situations in which scanning errors may occur and recommends strategies to address them.

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