Search results for "Information Professionals"

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

This commentary describes an electronic health record (EHR) oversight program to monitor and identify EHR-related safety hazards.

An automated surveillance system within an existing electronic medical record detected many more post-procedural adverse events than standard voluntary reporting.

This study describes the development and validation of a web-based tool that allows families to report adverse events during pediatric hospitalizations. The most frequent reports filed were around miscommunication between staff.

Physicians had a more negative view of incident reporting systems and tended to use more narrow and physician-centric descriptors when reporting an incident.

The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.

The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.

Though all hospitals are mandated to maintain an incident reporting system, there is limited evidence that such systems effectively detect patient safety problems or can reliably be used to improve safety. In this study, the authors provide a conceptual framework for using data from incident reporting systems to recognize and address safety issues. The model involves education about identifying, reporting, and analyzing events as well as implementing process changes to improve safety.

The investigators implemented a voluntary card-based error-reporting program and compared the results to those of an existing Web-based program. They found that reporting increased significantly with the card-based system.

The authors assessed residents' incident reporting using personal digital assistants (PDAs) and found that the technology, supported by a blame-free environment, contributed to the strong response by the trainees.

The authors review the literature on shift reports and communication of patient information and discuss how to enhance this process through automation.