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Search results for "Information Professionals"

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Journal Article > Study

Using FDA reports to inform a classification for health information technology safety problems.

Magrabi F, Ong MS, Runciman W, Coiera E. J Am Med Inform Assoc. 2012;19:45-53.

This study reviewed nearly 900,000 reports from the FDA Manufacturer and User Facility Device Experience database (MAUDE) and identified 678 reports describing health information technology issues. Investigators uncovered problems with software functionality, system configuration, interface with devices, and network configuration as new categories to the existing classification system.

Journal Article > Study

Implications of electronic health record downtime: an analysis of patient safety event reports.

Larsen E, Fong A, Wernz C, Ratwani RM. J Am Med Inform Assoc. 2017 May 30; [Epub ahead of print].

When electronic health records are out of use, either for planned upgrades or because of unexpected malfunction, this downtime disrupts usual hospital workflow. This study conducted an automated text search to identify incident reports related to electronic record downtime and analyzed the selected reports. Electronic health record downtime led to issues with laboratory testing including specimen identification errors and delayed transmission of results. Medication administration errors were also prevalent during downtime. Researchers found that downtime could hinder patient identification and information availability, which may result in serious safety hazards. The authors advocate for development of more comprehensive downtime procedures to address safety concerns as well as more consistent adherence to existing procedures.

Journal Article > Study

Screening electronic health record–related patient safety reports using machine learning.

Marella WM, Sparnon E, Finley E. J Patient Saf. 2017;13:31-36.

Voluntary error reporting systems are an important part of safety improvement programs, but difficulty in analyzing error reports has limited their utility. This study described the development of a machine learning algorithm to analyze free-text data in incident reports. The algorithm proved to be accurate in classifying events when compared to manual review.

Journal Article > Study

Electronic approaches to making sense of the text in the adverse event reporting system.

Benin AL, Fodeh SJ, Lee K, Koss M, Miller P, Brandt C. J Healthc Risk Manag. 2016;36:10-20.

Voluntary incident reports are critical to identifying adverse events, but reading through the text can be time-intensive. This study found that a machine learning approach to electronically analyze incident reports successfully detected both weight-based errors and patient identification errors. The authors conclude that it is feasible to apply automated text analysis to incident reports to categorize safety events and drive improvement.

Journal Article > Commentary

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

Robinson SN, Neyens DM, Diller T. Am J Med Qual. 2017;32:285-291.

There is a recognized challenge in developing true opportunities for improvement with incident reporting. Using a case study method, this commentary describes a tested incident assessment framework that employs charting mechanisms to monitor both harm and nonharm events that result in process or workflow changes to indicate reliability of care in real time.

Journal Article > Study

Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints.

Harrison R, Walton M, Healy J, Smith-Merry J, Hobbs C. Int J Qual Health Care. 2016;28:240-245.

This study applied a patient complaint taxonomy to complaints reported over a 5-year period to a large organization in Australia. Researchers were able to assign each of the complaints to one of the domains of the original taxonomy, but they discovered potential refinements to the model that may improve widespread applicability.

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 > Commentary

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports.

Ratwani RM, Fong A. J Am Med Inform Assoc. 2015;22:312-317.

This commentary describes the design and development of hospital-level and system-level dashboards representing data from patient safety event reporting systems as a way to reduce the burden of analyzing internal incident reports, increase awareness of adverse event trends, and enable utilization of the data to inform improvement.

Journal Article > Study

Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.

Provenzano A, Rohan S, Trevejo E, Burdick E, Lipsitz S, Kachalia A. BMJ Qual Saf. 2015;24:31-37.

Early efforts to characterize patient safety included the review of individual cases of patient deaths; mortality reviews remain a core aspect of hospital safety efforts. This study describes the implementation of an electronic tool which directly queries clinicians about specific cases of inpatient deaths. The authors determined that the tool was feasible to implement, and clinicians reported delays in accessing or responding to tests, communication barriers, and health care–associated infections as contributors to preventable inpatient mortality. When comparing clinician responses to administrative data, there was little agreement about the presence of complications, with neither source consistently identifying more complications. This work suggests that directly engaging with clinicians about inpatient mortality yields useful patient safety data beyond what chart review can provide and underscores the need to improve existing clinical documentation to support safety efforts.

Journal Article > Study

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

McKaig D, Collins C, Elsaid KA. Jt Comm J Qual Patient Saf. 2014;40;9:398-407.

Hospital incident reporting systems are ubiquitous, but many events remain unreported. This pre-post study sought to determine the impact of a reengineered medication error reporting approach. Researchers implemented a Web-based electronic medication error reporting system in concert with a novel work process in which clinical managers perform the first review of the report. The intervention led to increased error reporting, with the majority of errors being near-misses. This finding suggests that under-reporting of medication errors via standard incident reporting mechanisms can be addressed using human factors engineering approaches, which apply to and enhance both the error reporting tool and clinicians' workflow. A past AHRQ WebM&M perspective discusses how human factors engineering can be used to uncover problems with device design and work processes.

Journal Article > Commentary

Adverse events in healthcare: learning from mistakes.

Rafter N, Hickey A, Condell S, et al. QJM. 2015;108:273-277.

This review discusses chart reviews, trigger tools, and voluntary reporting as approaches to monitor adverse events and explores how lack of a standard method to collect and analyze data can hinder progress in determining trends and learning from reported information.

Journal Article > Study

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

Call RJ, Burlison JD, Robertson JJ, et al. 2014;165:447-452.

To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.

Journal Article > Commentary

The next organizational challenge: finding and addressing diagnostic error.

Graber ML, Trowbridge R, Myers JS, Umscheid CA, Strull W, Kanter MH. Jt Comm J Qual Patient Saf. 2014;40:102-110.

Although diagnostic errors cause considerable morbidity and mortality, thus far organizations have focused on preventing errors that are more easily measured. This commentary provides two examples of organizational approaches to minimizing diagnostic error. In one, Maine Medical Center established a voluntary reporting system for diagnostic error coupled with a revised root cause analysis process to determine both cognitive and systems causes of these errors. In the other example, the Kaiser Permanente system leveraged their electronic medical record to establish electronic "safety nets" to identify patients at risk of diagnostic error. These mainly focused on ensuring appropriate follow-up of abnormal lab tests (particularly cancer screening tests) and sufficient monitoring of high-risk medications. As failure to appropriately follow-up on lab abnormalities is a common source of patient harm in ambulatory care, this system—which identified thousands of patients requiring urgent follow-up—likely averted many cases of preventable harm. An accompanying editorial by Dr. Hardeep Singh encourages health care organizations to develop processes for examining missed opportunities for making timely diagnoses.

Journal Article > Study

Identification of serious and reportable events in home care: a Delphi survey to develop consensus.

Doran DM, Baker GR, Szabo C, McShane J, Carryer J. Int J Qual Health Care. 2014 26:136-143.

Home care is one of the fastest growing sectors of the health care field, but recent research has raised safety concerns among patients receiving home services. A prospective cohort study revealed that 10% of home care patients experienced an adverse event, an incidence comparable to that found in hospitalized patients. This study used a Delphi approach to determine the types of adverse events in home care that should be considered serious (in terms of the level of patient harm) and preventable. Four types of serious preventable events were identified: inappropriate client service plans, medication errors requiring emergency treatment, catheter-associated infections, and incidents related to care that did not fall within practice standards. The authors advocate for using this classification scheme as the basis for a home care adverse event reporting system, analogous to state reporting systems for serious errors occurring in hospitalized patients.

Journal Article > Review

What to do with healthcare incident reporting systems.

Pham JC, Girard T, Pronovost PJ. J Public Health Res, 2013;2:e27.

Incident reporting systems are a popular method for hospitals to detect patient safety hazards. This review highlights limitations and strengths of incident reporting in safety improvement programs and makes recommendations to enhance their usefulness, including prioritizing and examining incidents to identify which events occur more often or lead to more harm.

Journal Article > Study

Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors.

Lederman R, Dreyfus S, Matchan J, Knott JC, Milton SK. Nurs Outlook. 2013;61:417-426.e5.

This qualitative study found considerable barriers to nurses' use of an electronic incident reporting system, ranging from confusion about which errors should be reported to technical problems with the systems interface and usability.

Journal Article > Study

Reported medication errors after introducing an electronic medication management system.

Redley B, Botti M. J Clin Nurs. 2013;22:579-589.

This study characterizes the types of medication errors documented after introduction of a comprehensive electronic medication management system (that included computerized provider order entry) at two Australian hospitals.

Journal Article > Study

Adverse events are common on the intensive care unit: results from a structured record review.

Nilsson L, Pihl A, Tågsjö M, Ericsson E. Acta Anaesthesiol Scand. 2012;56:959-965.

This study used the Global Trigger Tool to identify adverse events in intensive care unit patients at a Swedish hospital and found that nearly 1 in 5 patients suffered an adverse event, half of which were preventable.

Award > Award Recipient

Reporting Patient Safety Events Challenge.

Washington, DC: Office of the National Coordinator for Health Information Technology; 2012.

This announcement describes the winner of an award for the development of software promoting incident reporting by both acute and ambulatory care providers.

Journal Article > Study

Automated identification of extreme-risk events in clinical incident reports.

Ong MS, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:e110-e118.

Incident reports can yield useful information about safety problems, but manual review of all voluntary error reports is time intensive and often low yield. This study reports on the use of informatics technology to screen incident reports in order to identify high-severity safety problems.

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