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Search results for "Information Professionals"

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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.

Journal Article > Commentary

Medical research and the Institutional Review Board: the librarian's role in human subject testing.

Robinson JG, Gehle JL. Ref Serv Rev. 2005;33:20-24.

The authors discuss their organization's response to a 2001 incident in which an incomplete bibliographic review played a role in the death of a research volunteer. They outline an initiative to involve librarians in evidentiary review for clinical trials to ensure the safety of research subjects.

Journal Article > Study

Improving communication with primary care physicians at the time of hospital discharge.

Destino LA, Dixit A, Pantaleoni JL, et al. Jt Comm J Qual Patient Saf. 2017;43:80-88.

Adverse events after hospital discharge are common. Prior research demonstrates that communication and information transfer between inpatient providers and primary care physicians (PCPs) may be lacking, raising patient safety concerns. This study described how applying Lean methodology, enhancing frontline provider engagement, and redesigning workflow processes within the electronic health record led to improved communication with PCPs around the time of hospital discharge. Through these interventions, the pediatric medical service was able to increase verbal communication with PCPs at discharge to 80%, and they sustained this for a 7-month period. Discharge communication with PCPs across other services improved as well. A previous PSNet perspective discussed the challenges associated with care transitions and suggested opportunities for improvement.

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.

Perspectives on Safety > Interview

In Conversation With… Andrew Bindman, MD

New Leaders in Safety and Quality, November 2016

Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.

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

Frequency of passive EHR alerts in the ICU: another form of alert fatigue?

Kizzier-Carnahan V, Artis KA, Mohan V, Gold JA. J Patient Saf. 2016 Jun 22; [Epub ahead of print].

This study found that laboratory values designated as "abnormal" or "panic" in the electronic health record, which are considered passive alerts, are very common for patients in the intensive care unit. The authors suggest that these passive alerts contribute to the pervasive problem of alert fatigue in the intensive care unit.

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.

Book/Report

Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.

Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.

Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.

Journal Article > Study

A prospective controlled trial of an electronic hand hygiene reminder system.

Ellison RT III, Barysauskas CM, Rundensteiner EA, Wang D, Barton B. Open Forum Infect Dis. 2015;2:ofv121.

Hand hygiene remains one of the most basic targets for enhancing patient safety. Poor hand hygiene compliance persists despite multiple global efforts, and a recent study showed handwashing rates are likely even lower when there is not a direct observer recording compliance. This prospective controlled trial in two medical intensive care units (ICUs) studied the effect of an electronic reminder system. An audible chime for each room entry and exit initially increased handwashing events in the test ICU, but this effect quickly declined, likely related to alert fatigue. In contrast, a combination of a chime and real-time computer monitor feedback of current hygiene compliance rates resulted in an increase that lasted throughout the study phase. Once the reminder system was turned off, compliance rates returned to the previous baseline. Overall hand hygiene compliance rates were quite low: recorded handwashing occurred in only about one-third of room entries or exits. A prior AHRQ WebM&M perspective reviewed innovations in promoting hand hygiene compliance.

Journal Article > Study

Problem list completeness in electronic health records: a multi-site study and assessment of success factors.

Wright A, McCoy AB, Hickman TT, et al. Int J Med Inform. 2015;84:784-790.

A patient problem list is a catalog of all health issues affecting a patient. Problem lists in electronic health records (EHRs) can play important roles for patient care and help identify target populations for quality improvement interventions or research studies. However, to serve these purposes, the problem list must be accurate and complete. This international study examined 10 health care organizations that use different EHRs in the United States, United Kingdom, and Argentina. Using the test case example of a diabetes diagnosis for any patient that had a recorded hemoglobin A1c value of greater than 7% (a test result that is diagnostic for diabetes), problem list completeness was found to range from 60% to 99% across the 10 sites. The authors conducted interviews with informatics leaders at the four top performing sites to determine factors that may contribute to higher success rates. Some practices that were common among the top performers were financial incentives, problem-oriented charting, gap reporting, shared responsibility, and links to billing codes. A prior AHRQ WebM&M commentary illustrates a patient care issue that arose due to an inaccurately recorded problem list.

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 > Review

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews.

Ryan R, Santesso N, Lowe D, et al. Cochrane Database Syst Rev. 2014;4:CD007768.

This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.

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

How do community pharmacies recover from e-prescription errors?

Odukoya OK, Stone JA, Chui MA. Res Social Adm Pharm. 2014;10:837-852.

The handwritten prescription pad is vanishing from clinical practice, replaced by the proliferation of e-prescribing. There are many advantages to this technology, but prescribing errors still occur at alarming rates. This study explored the approaches community pharmacists and technicians utilize to detect and manage e-prescription errors.

Book/Report

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309293099.

Cancer patients are particularly vulnerable to preventable errors in both inpatient and outpatient settings, as their care involves exposure to high-risk medications and requires closely coordinated care. Seen in that light, this Institute of Medicine report, which bluntly concludes that the current system of cancer care is untenable, is particularly concerning. The report highlights numerous deficiencies in the current system, such as insufficient compliance with evidence-based guidelines, high rates of medication errors, and failure to incorporate patient preferences into advanced care planning. To reshape how cancer care is delivered, the report recommends leveraging information technology to augment care coordination and real-time analysis of treatment data, better end-of-life planning, and improving communication with patients and families around prognosis and the risks and benefits of treatments. Multiple AHRQ WebM&M commentaries discuss safety issues in oncology patients, including a case of a chemotherapy medication error detected by the patient himself and a near-fatal error ascribed in part to poorly coordinated care.

Book/Report

Health IT-Enabled Quality Measurement: Perspectives, Pathways, and Practical Guidance.

Roper RA, Anderson KM, Marsh CA, Flemming AC. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0059-EF.

This publication reports recommendations from a focus group exploring the utility of health information technology in enhancing quality measurement and discusses how the data can be used to improve care.

Journal Article > Study

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system.

Dixon-Woods M, Redwood S, Leslie M, Minion J, Martin GP, Coleman JJ. Milbank Q. 2013;91:424-454.

Ethnographic observations and semi-structured interview data showed that implementation of an electronic health record with prescribing and decision support led to greater oversight of and improvements in specific safety metrics.

Journal Article > Commentary

Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.

Turakhia MP, Estes NA 3rd, Drew BJ, et al; Electrocardiography and Arrhythmias Committee of the American Heart Association Council on Clinical Cardiology and Council on Cardiovascular Nursing. Circulation. 2012;126:1665-1669.

This commentary details how the delay of electrocardiogram data distributed via wireless telemetry systems can affect patient safety and provides recommendations to prevent and mitigate such delays.

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