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Search results for "Information Professionals"

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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.

Journal Article > Study

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

  • Classic

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.

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

Exploring situational awareness in diagnostic errors in primary care.

Singh H, Davis Giardina T, Petersen LA, et al. BMJ Qual Saf. 2012;21:30-38.

Diagnostic errors are a known threat to patient safety, and measuring their prevalence is challenging, particularly outside pathology and radiology settings. Past studies have highlighted classification systems and related prevention strategies, including the adoption of checklists. This study explored the use of a situational awareness (SA) framework to understand diagnostic errors in a primary care setting. Investigators interviewed providers involved in a diagnostic error and revealed that one level of SA was lacking (e.g., information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels). The authors found that applying the SA framework to analyze such errors provided deeper insight into the provider–work system interaction, which included important interface with the electronic health record. A past AHRQ WebM&M perspective and interview discussed diagnostic errors in medicine.

Perspectives on Safety > Interview

In Conversation with… Edward Tenner, PhD

Unintended Consequences, June 2011

His seminal work in patient safety is generally credited with introducing the concept of unintended consequences.

Journal Article > Study

Risk-sensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool.

Buzink SN, van Lier L, de Hingh IHJT, Jakimowicz JJ. Surg Endosc. 2010;24:1990-1995.

This study found that use of an integrated operating room (OR) system and a digital checklist tool reduced risk-sensitive events more than using an integrated OR alone.

Journal Article > Review

What have we learned about interventions to reduce medical errors?

Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-497.

This narrative review provides a broad perspective on the current understanding of medical errors and the evidence behind commonly adopted prevention strategies. The authors then highlight a series of recommendations to improve patient safety.

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.

Journal Article > Study

Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.

Sard BE, Walsh KE, Doros G, et al. Pediatrics. 2008;122:782-787.

Standardizing care processes, through the use of checklists and other approaches, has been demonstrated to improve patient safety by reducing health care–associated infections and handoff errors. This study implemented a standardized "quicklist" of commonly used pediatric medications within an existing computerized provider order entry system. Although use of the quicklist was not mandatory, prescribing errors were significantly reduced, especially among those providers who used the quicklist regularly. The study provides an example of how standardization combined with decision support can improve medication safety.

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.

Cases & Commentaries

Glucose Roller Coaster

  • Web M&M

Bradley A. Sharpe, MD; July 2004

A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.

Cases & Commentaries

Fumbled Handoff

  • Web M&M

Arpana Vidyarthi, MD; March 2004

Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.

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