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Search results for "Information Professionals"

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Journal Article > Commentary

Making healthcare safer by understanding, designing and buying better IT.

Thimbleby H, Lewis A, Williams J. Clin Med. 2015;15:258-262.

Design weaknesses for medical devices can remain unrecognized due to insufficient reporting and the tendency to place blame on the user rather than question whether the equipment functioned appropriately. Discussing flaws in health IT design and how they can contribute to patient harm, this commentary advocates for enhanced reporting of device-related incidents to raise awareness about risks and enable learning from errors.

Journal Article > Study

The mixed blessings of smart infusion devices and health care IT.

Nemeth CP, Brown J, Crandall B, Fallon C. Mil Med. 2014;179(suppl 8):4-10.

This study provides a detailed description of the overlapping technological, organizational, and human factors associated with the use of smart pumps and includes insights into potential pitfalls that may pose patient safety threats. The authors make specific recommendations to improve the real-world use of smart pump technology.

Journal Article > Study

Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

Mason JJ, Roberts-Turner R, Amendola V, Sill AM, Hinds PS. J Pediatr Nurs. 2014;29:143-151.

In this study, surveys found that pediatric nurses perceive that smart infusion pumps improve patient safety. Accompanying data captured by smart pumps supported that perception, documenting 65 instances in which those same nurses prevented medication errors by appropriately utilizing the devices.

Journal Article > Study

Evaluating alert fatigue over time to EHR-based clinical trial alerts: findings from a randomized controlled study.

Embi PJ, Leonard AC. J Am Med Inform Assoc. 2012;19:e145-e148.

Clinical decision support systems (CDSS) are being applied widely in patient safety, most frequently to provide alerts intended to prevent medication errors. The utility of such warnings is limited by alert fatigue—clinicians' tendency to ignore repeated alerts. This study of an alert within an electronic medical record designed to encourage participation in a clinical trial is relevant for CDSS designers, as it quantifies the degree of alert fatigue. The study found that response rates to the alert declined consistently over time in response to increased exposure to the alert. A recent commentary called for CDSS to be tailored to maximize safety outcomes while minimizing alert fatigue.

Newspaper/Magazine Article

Safety in numbers? Try connectivity.

Dyell D. Patient Saf Qual Healthc. January/February 2012;9:34-37.

This magazine article describes problems with medical devices and recommends that device connectivity and integration can improve safety.

Newspaper/Magazine Article

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

This news article reviews actual and potential medication errors submitted to the Institute for Safe Medication Practices in 2010 and provides recommendations to address them.

Journal Article > Study

Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.

Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.

Implementation of smart intravenous pumps was associated with fewer adverse events and considerable cost savings at an academic medical center.

Perspectives on Safety > Perspective

The Safety of Medical Devices

with commentary by Christopher Nemeth, PhD, Unintended Consequences, June 2011

This piece discusses how adopting new technology can have unintended effects.

Journal Article > Study

Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.

Cima RR, Kollengode A, Clark J, et al. Jt Comm J Qual Patient Saf. 2011;37:51-58.

This study implemented a data-matrix–coded sponge system that eliminated retained sponges while causing no significant disruption in operating time or workflow.

Newspaper/Magazine Article

FDA discusses oversight, regulation of HIT at ONC Workgroup hearing on patient safety.

Health IT Law & Industry Report; February 26, 2010.

This news article covers federal testimony in support of health information technology (HIT) system regulation by the United States Food and Drug Administration (FDA). The piece describes safety concerns that could result from HIT and discusses potential regulatory approaches to improvement, such as third-party reporting, confidentiality, and limited liability.

Journal Article > Commentary

Connectivity to improve patient safety.

Whitehead SF, Goldman JM. Patient Saf Qual Healthcare. January/February 2010;7:26-30.

This article discusses how adopting open standards for medical device interoperability can help advance patient safety and reports on a 5-year multidisciplinary project related to this goal.

Journal Article > Study

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

Implementation of smart infusion pumps resulted in both improved patient safety and cost savings, making a strong business case for investing in this patient safety intervention.

Cases & Commentaries

Eptifibatide Epilogue

  • Web M&M

William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009

A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.

Perspectives on Safety > Perspective

The Role of Bar Coding and Smart Pumps in Safety

with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008

Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.

Newspaper/Magazine Article

"Plug and Play" hospitals: medical devices that exchange data could make hospitals safer.

Grifantini K. Technol Rev. July 9, 2008.    

This article reports on two projects developed at the Center for Integration of Medicine and Innovative Technology that demonstrate functional device interoperability in hospital operating rooms.

Journal Article > Study

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23(suppl 1):41-45.

Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.

Book/Report

Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition.

London, England: The Helen Hamlyn Research Centre and the National Patient Safety Agency; 2007.

This illustrated report provides guidelines for the packaging of pharmaceuticals along with an information design checklist for minimizing medication error.

Journal Article > Study

Increasing vigilance on the medical/surgical floor to improve patient safety.

Jacobs JL, Apatov N, Glei M. J Adv Nurs. 2007;57:472-481.

The authors describe an automated, non-invasive technology used to monitor patients' heart and respiration rates. The present study provides ''proof of concept'' data only, indicating that the technology accurately captures cardiorespiratory telemetry events of interest and did so with a very low rate of false alarms. As the authors acknowledge, future work will need to assess the system's impact on patient outcomes and its integration into the nursing workflow.

Journal Article > Commentary

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

The author discusses high-risk intravenous infusions, smart pump technologies that support safe delivery of medications, and effective use of smart pump data to inform improvements.

Newspaper/Magazine Article

Ensuring patient safety in wireless medical device networks.

Gehlot V, Sloane EB. Computer. April 2006;39:54-60.

The authors discuss clinical alarm systems from a technical perspective and propose a toolkit to help make complex clinical IT systems more technically reliable.

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