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Search results for "Information Professionals"

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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

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and 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 > 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.

Journal Article > Study

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

Murphy DR, Thomas EJ, Meyer AND, Singh H. Radiology. 2015;277:81-87.

Delays in follow-up of abnormal test results are known to contribute to delayed and missed diagnosis. Investigators developed and validated an electronic trigger to identify potential delays in follow-up of abnormal chest computed tomography scans. This study found that more than half of the flagged cases had a true diagnostic delay. This work should lead to prospective evaluation of trigger approaches to enhance test result follow-up.

Journal Article > Study

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.

Dalal AK, Pesterev BM, Eibensteiner K, Newmark LP, Samal L, Rothschild JM. J Am Med Inform Assoc. 2015;22:905-908.

Failure to follow-up on test results in ambulatory practice is a common, serious safety concern. This study examined the use of a results manager tool by primary care physicians in Partners Healthcare in Boston. Although the vast majority of providers used the tool, many did not find that it was helpful for any specific purpose and only 64% were satisfied with the tool.

Journal Article > Study

Reducing emergency department charting and ordering errors with a room number watermark on the electronic medical record display.

Yamamoto LG. Hawaii J Med Public Health. 2014;73:322-328.

This survey found that physicians chart or write orders in the wrong patient's electronic health record 1.3% of the time, with significant errors for nurses and clinical assistants as well. Respondents believed that a simple solution such as a prominent room number watermark on the screen would prevent such errors, reinforcing the need to be able to augment electronic health record interfaces to improve safety.

Journal Article > Study

The automated operating room: a team approach to patient safety and communication.

Nissan J, Campos V, Delgado H, Matadial C, Spector S. JAMA Surg. 2014;149:1209-1210.

The introduction of an automated workflow system, which provides a common display of perioperative data elements to every member of the surgical team, improved operative checklist compliance and nearly doubled the number of cases that started on time. The majority of nurses felt this system enhanced patient safety.

Journal Article > Review

Electronic medical record: a balancing act of patient safety, privacy and health care delivery.

Gummadi S, Housri N, Zimmers TA, Koniaris LG. Am J Med Sci. 2014;348:238-243.

Electronic health records (EHRs) and health information technologies (IT) have been widely implemented to enhance safe care delivery, despite weaknesses linked to systems and user experience. This review explores the evidence on health IT implementation and design challenges that have hindered progress, recommends ways to address these issues, and highlights the potential benefits if EHRs are fully utilized.

Journal Article > Study

Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."

Ching JM, Williams BL, Idemoto LM, Blackmore CC. Jt Comm J Qual Patient Saf. 2014;40:341-350.

This study highlights the use of Lean methodologies to facilitate implementation of barcode medication administration (BCMA) for hospitalized patients at Virginia Mason Medical Center. The introduction of BCMA led to significantly fewer medication errors. The concepts presented may be helpful for organizations employing new health technologies.

Journal Article > Study

Are amended surgical pathology reports getting to the correct responsible care provider?

Parkash V, Domfeh A, Cohen P, et al. Am J Clin Pathol. 2014;142:58-63.

In this chart review study, amended pathology reports with clinically significant patient results did not reliably reach treating clinicians. Despite prior studies highlighting the shortcomings of test results reporting, this patient safety issue persists.

Book/Report

Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation.

Grossman JM, Gourevitch R, Cross D. Washington, DC: National Institute for Health Care Reform; July 2014. NIHCR Research Brief No. 17.

According to this report, many vendors are still working to add and implement enhanced functions for electronic health records to support medication reconciliation capabilities. Health care workers are instead employing hybrid paper-electronic processes to ensure patients' medication lists remain accurate throughout their hospital stay.

Journal Article > Study

Indication alerts intercept drug name confusion errors during computerized entry of medication orders.

Galanter WL, Bryson ML, Falck S, et al. PLoS One. 2014;9:e101977.

Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Confusion between medications with names that appear or sound similar is a common cause of medication errors. This observational study sought to determine whether a computerized provider order entry system—with an alert that prompted providers to enter the indication when certain medications were ordered and required users to click "OK" to ignore the alert, to add the drug to a problem list, or to cancel the order—identified drug name confusion errors. These alerts intercepted 1.4 drug name confusion errors per 1000 alerts. While authors recommend that these alerts be implemented to decrease medication errors, they suggest narrowing the number of medications selected to prompt alerts to reduce risk of alert fatigue. A previous AHRQ WebM&M commentary describes an incident involving a look-alike drug error and reviews strategies to enhance safety of medication selection.

Journal Article > Study

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

Hardmeier A, Tsourounis C, Moore M, Abbott WE, Guglielmo BJ. J Healthc Qual. 2014;36:54-63.

After implementation of a barcode medication administration system at a children's hospital, adherence to institutional medication safety protocols was high and the incidence of medication administration errors appeared to be low based on direct observation.

Newspaper/Magazine Article

Health-care providers want patients to read medical records, spot errors.

Landro L. Wall Street Journal. June 9, 2014.

As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.

Journal Article > Review

Automated and electronically assisted hand hygiene monitoring systems: a systematic review.

Ward MA, Schweizer ML, Polgreen PM, Gupta K, Reisinger HS, Perencevich EN. Am J Infect Control. 2014;42:472-478.

This systematic review evaluated new technologies for assisting hand hygiene monitoring, including automated counting systems, video monitoring, and fully automated monitoring systems. Currently, there is very limited data about how accurate, effective, and valuable these strategies are in enhancing hand hygiene compliance.

Journal Article > Study

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

Franklin BD, Reynolds M, Sadler S, et al. BMJ Qual Saf. 2014;23:629-638.

This study of medication dispensing errors at community pharmacies found that electronic transmission of prescriptions resulted in increased omission of the medication indication, but that other error types did not change. These findings suggest that electronic prescribing alone is not sufficient to address outpatient dispensing errors.

Journal Article > Review

Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting.

Porterfield A, Engelbert K, Coustasse A. Perspect Health Inf Manag. 2014;11:1.

Exploring the impact of electronic prescribing in ambulatory care, this review describes benefits such as decreased rates of medication errors, cost savings, and improved patient adherence. The author also identifies challenges to implementation, including concerns about cost, privacy, and poorly designed systems.

Journal Article > Review

Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations.

Weis JM, Levy PC. Chest. 2014;145:632-638.

Adoption and implementation of electronic health records have raised concerns about the ability to copy and paste. Highlighting the prevalence of using copy and paste to update electronic medical documentation, this commentary relates how this might facilitate communication and introduce risks to patient care.

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