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Search results for "Information Professionals"

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Journal Article > Commentary

Technology, cognition and error.

Coiera E. BMJ Qual Saf. 2015;24:417-422.

Providers and policymakers have raised concerns about risks associated with health information technology (IT). This commentary spotlights the importance of considering human factors and cognition when designing health IT systems to understand how human–computer interaction can contribute to error.

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.

Journal Article > Review

A systematic review of the psychological literature on interruption and its patient safety implications.

  • Classic

Li SY, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.

Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.

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 > Review

Checking the lists: a systematic review of electronic checklist use in health care.

Kramer HS, Drews FA. J Biomed Inform. 2016 Sep 10; [Epub ahead of print].

Checklists are widely utilized in health care to improve patient safety. In this systematic review, investigators examined the use of electronic checklists in health care. They recommend that further research should focus on implementation and checklist design.

Book/Report

Report on the Safe Use of Pick Lists in Ambulatory Care Settings.

Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.

Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.

Journal Article > Study

Incidence of speech recognition errors in the emergency department.

Goss FR, Zhou L, Weiner SG. Int J Med Inform. 2016;93:70-73.

The adoption of new technology in health care often produces unintended consequences, which can be mitigated by applying human factors engineering principles to user interface design. Due to efficiency gains, the use of speech recognition technology among physicians has grown in recent years. Investigators analyzed notes dictated by emergency medicine physicians and found that 71% of the notes contained errors. Given that 15% of the errors were considered critical, the authors suggest speech recognition technology may create miscommunication that could adversely affect patient care.

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 > Commentary

Why 'Universal Precautions' are needed for medication lists.

Shane R. BMJ Qual Saf. 2016;25:731-732.

Despite the support for maintaining medication lists in electronic health records, these lists can contain and perpetuate errors. This commentary suggests that a set of standards are needed to ensure accuracy of electronic medication lists and reduce unnecessary or duplicate prescriptions in discharge instructions.

Journal Article > Study

Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.

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Overdyk FJ, Dowling O, Newman S, et al. BMJ Qual Saf. 2016;25:947-953.

Use of the surgical safety checklist has been linked to improved patient outcomes, but checklist compliance has been variable. In this prospective trial, operating rooms (ORs) were equipped with remote video auditing and then cluster-randomized to either receive, or not receive, real-time feedback. Sign-in, timeout, and signout rates improved dramatically in both groups compared to the low baseline rates. ORs that received real-time feedback had significantly higher compliance scores than those that just had video recordings. Following this study period, all ORs received real-time feedback, resulting in pass rates up to 91% for sign-in, 95% for timeout, and 84% for signout. Mean turnover times for scheduled cases decreased with feedback, indicating enhanced efficiency. An accompanying editorial calls implementing videos with feedback the "next great leap forward" for patient safety. A recent PSNet perspective discussed the benefits of using video in clinical and educational settings.

Newspaper/Magazine Article

Medication errors involving overrides of healthcare technology.

Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148.

Users often bypass alerts meant to enhance safety of medication ordering and dispensing technologies. This article analyzes reports submitted to the Pennsylvania Patient Safety Authority to determine the types of technologies and medications frequently associated with overrides and recommends strategies to reduce risk of alarm fatigue.

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.

Journal Article > Study

Enhancing surgical safety using digital multimedia technology.

Dixon JL, Mukhopadhyay D, Hunt J, Jupiter D, Smythe WR, Papaconstantinou HT. Am J Surg. 2016;211:1095-1098.

In this study, researchers developed a system for surgical time-outs where scanning a patient's wristband launches a presentation on the operating room monitor, which includes a video of the patient stating his or her name, date of birth, surgical procedure, and operative laterality. Although these took longer than standard timeouts (79 seconds versus 49 seconds), 87% of operating room personnel preferred the digital version, and performance of key safety elements significantly improved.

Journal Article > Study

Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.

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Lacson R, O'Connor SD, Sahni VA, et al. BMJ Qual Saf. 2016;25:518-524.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Journal Article > Study

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

Dekarske BM, Zimmerman CR, Chang R, Grant PJ, Chaffee BW. Int J Med Inform. 2015;84:1085-1093.

Alert fatigue is the Achilles heel of medication ordering with computerized physician order entry. This randomized controlled trial found that the appropriateness of alert overrides increased with implementation of a customized list of alert override reasons, compared with default options, in a CPOE system. This demonstrates the need to develop more clinically relevant reasons for overriding alerts in order to enhance the safety of medication prescribing.

Journal Article > Study

Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care.

Cifuentes M, Davis M, Fernald D, Gunn R, Dickinson P, Cohen DJ. J Am Board Fam Med. 2015;28(suppl 1):S63-S72.

This observational study of 11 community practices that had integrated behavioral health and primary care describes the challenges related to electronic health records that do not specifically support integrated care delivery functions. There were issues with documentation, tracking, communication, and coordination of care, requiring practices to develop workarounds such as double data entry, scanning and uploading documents, or using separate tracking systems.

Journal Article > Study

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.

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Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. J Clin Oncol. 2015;33:3560-3567.

Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.

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.

Cases & Commentaries

Baffled by Botulinum Toxin

  • Web M&M

Krishnan Padmakumari Sivaraman Nair, DM; July/August 2015

A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.

Book/Report

Examining the Relationship Between Health IT and Ambulatory Care Workflow Redesign.

Zheng K, Ciemins EL, Lanham HJ, Lindberg C. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.

Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.

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