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Search results for "Information Professionals"

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Journal Article > Review

State-of-the-art usage of simulation in anesthesia: skills and teamwork.

Krage R, Erwteman M. Curr Opin Anaesthesiol. 2015;28:727-734.

Simulation training is a common method to enhance technical and nontechnical skills in health care. This review discusses simulation training in anesthesia and emphasizes the importance of learning objectives and activity design to drive success in high- and low-fidelity programs.

Journal Article > Review

Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis.

Berdot S, Roudot M, Schramm C, Katsahian S, Durieux P, Sabatier B. Int J Nurs Stud. 2016;53:342-350.

This meta-analysis examined the efficacy of interventions to improve the safety of medication administration. Researchers looked at studies that used training methods (e.g., simulation) and technology approaches (e.g., computerized physician order entry and automated medication dispensing systems). The authors conclude that more randomized or experimental trials are needed in order to characterize the effect of these interventions, although they acknowledge the increasing implementation of barcode medication administration as a safety strategy.

Journal Article > Review

An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains.

Johnston MJ, Paige JT, Aggarwal R, et al; Association for Surgical Education Simulation Committee. Am J Surg. 2016;211:214-225.

Simulation has been explored as a way to improve teamwork, crisis management, and technical skills in surgery. This review analyzes the evidence base on surgical simulation and identifies areas of progress, including curricula development, training techniques, and feedback methods. However, there is still a lack of data confirming the impact of simulation interventions on patient outcomes.

Journal Article > Commentary

Functional safety of health information technology.

Chadwick L, Fallon EF, van der Putten WJ, Kirrane F. Health Informatics J. 2012;18:36-49.

Discussing how safety concepts from other high-risk domains can improve patient safety, this piece recommends that electrical system standards be applied to health information technology design and implementation.

Journal Article > Study

Citation classics in patient safety research: an invitation to contribute to an online bibliography.

Lilford R, Stirling S, Maillard N. Qual Saf Health Care. 2006;15:311-313.

Drawing from Agency for Healthcare Research and Quality's (AHRQ) 2001 comprehensive patient safety literature analysis, the authors determined the most cited and influential patient safety papers.

Journal Article > Study

The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.

Porat T, Delaney B, Kostopoulou O. BMC Med Inform Decis Mak. 2017;17:79.

The recent National Academy of Medicine report on improving diagnosis cited the need for enhanced clinical decision support. This pre–post study used a simulation approach (standardized patients) to compare visits with and without use of a diagnostic clinical decision aid embedded in the electronic health record. The patients' visit satisfaction ratings did not differ in the visits with and without the decision support, although more patients in the decision support group noted that physicians focused more on the computer than the patient. The physicians reported high overall satisfaction with the decision tool, but they noted that it required inputting more clinical documentation during the visit, resulting in more time directed at the electronic health record. The authors conclude that the clinical decision support tool interface should be improved in order to facilitate adoption of real-time diagnostic support.

Journal Article > Study

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.

Walker AS, Mason A, Quan TP, et al. Lancet. 2017 May 9; [Epub ahead of print].

The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.

Journal Article > Commentary

Introducing a new junior doctor electronic weekend handover on an orthopaedic ward.

Maroo S, Raj D. BMJ Qual Improv Rep. 2017;6:u212695.w5059.

Handoffs and weekend care are two error-prone elements of health care. This commentary describes a project that focused on shifting from a paper-based to an electronic handoff process to enhance handover reliability over the weekend. The authors explain how using plan-do-study-act cycles helped augment implementation of the new handoff process. A recent PSNet interview discussed the weekend effect in health care.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Journal Article > Study

Prescription errors related to the use of computerized provider order-entry system for pediatric patients.

Alhanout K, Bun SS, Retornaz K, Chiche L, Colombini N. Int J Med Inform. 2017;103:15-19.

Computerized provider order entry has been shown to decrease adverse drug events, but it can also introduce new medication errors. This retrospective study examined medication ordering errors intercepted by pharmacists for pediatric patients. As with prior studies in pediatrics, this investigation uncovered dosing errors associated with weight-based dosing, including calculation errors and missing weight information. The most common medication associated with errors was acetaminophen, which can cause severe harm if incorrectly dosed. The authors call for improving electronic health record prescribing interfaces, better user training, and enhancing communication among providers to prevent medication errors.

Journal Article > Study

Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture.

Davies J, Pucher PH, Ibrahim H, Stubbs B. J Surg Res. 2017;212:222-228.

Although computerized provider order entry systems are widely implemented, a prior review suggests that their ability to reduce adverse drug events remains uncertain. Less is known about their impact on safety culture. Researchers administered a modified Safety Attitudes Questionnaire survey 6 weeks after the implementation of an electronic prescribing system across surgical services at one hospital and found a decline in safety culture.

Journal Article > Study

Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.

Mozaffar H, Cresswell KM, Williams R, Bates DW, Sheikh A. BMJ Qual Saf. 2017 Feb 7; [Epub ahead of print].

Although computerized provider order entry is known to reduce medication errors, previous research has demonstrated that electronic prescribing can introduce new medication safety risks. This observational qualitative study of electronic prescribing at six British hospitals included direct observation, interviews, and analysis of implementation documents. Investigators determined multiple unintended consequences of electronic prescribing, at every stage of use, and identified design flaws in electronic prescribing platforms. Suboptimal implementation of electronic prescribing, with partial functionality and insufficient training, increased risk of errors. Once electronic prescribing was in place, prescribers started using workarounds and relied too much on the prescribing platform. The authors call for design and organizational strategies to mitigate these safety concerns. A past WebM&M commentary described a medication error related to electronic prescribing.

Journal Article > Study

Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation.

  • Classic

Kostopoulou O, Porat T, Corrigan D, Mahmoud S, Delaney BC. Br J Gen Pract. 2017;67:e201-e208.

Improving diagnosis in outpatient care is a patient safety priority. This simulation study evaluated the process of diagnosis in the primary care setting. Investigators contrasted physicians' diagnostic accuracy conducting a primary care visit in their usual manner versus using a clinical decision support tool. Each visit employed a standardized patient (an actor reporting symptoms consistent with a given diagnosis) and the visits with and without decision support were matched for complexity. The tool improved diagnostic accuracy significantly: 68% of visits using decision support reached the correct diagnosis versus 59% of usual care visits. The duration of visits and number of subspecialty consultations did not change with or without decision support. Physician participants rated the usability of the decision support tool favorably overall. These data suggest that decision support can be feasibly integrated into primary care to improve diagnostic accuracy.

Journal Article > Review

The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety.

Sax U, Lipprandt M, Röhrig R. Yearb Med Inform. 2016;1:130-137.

Given the dependence of clinical processes on health information technology (IT), potential risks resulting from inability to access those systems are a significant safety concern. This review discusses ways to protect against large-scale failures of health IT systems and categorizes the types of failures that can occur. The authors suggest that a culture of safety can facilitate learning and improvement across the industry.

Journal Article > Study

Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities.

Mira JJ, Carrillo I, Fernandez C, Vicente MA, Guilabert M. JMIR Mhealth Uhealth. 2016;4:e131.

Health information technology has the potential to facilitate patient safety tasks. This study described the development of a mobile health application for patient safety managers to enable activities such as tracking of risk management processes and safety audits. Users who tested the application reported high satisfaction with the tool, though its efficacy in enhancing safety was not studied.

Journal Article > Review

The application of the Global Trigger Tool: a systematic review.

Hibbert PD, Molloy CJ, Hooper TD, et al. Int J Qual Health Care. 2016;28:640-649.

The Institute for Healthcare Improvement's Global Trigger Tool is widely used to identify adverse events. This systematic review found variation in how the tool is implemented, with differing rates of adverse events detected. The authors suggest modifying the trigger tool to capture errors of omission and to assess the preventability of events identified.

Journal Article > Study

Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.

Pontefract SK, Hodson J, Marriott JF, Redwood S, Coleman JJ. PLoS One. 2016;11:e0160075.

Although electronic health records (EHRs) with computerized provider order entry are known to improve medication safety, experts have raised concerns that EHRs adversely affect interprofessional communication by reducing personal interactions among providers. This study examined unidirectional computerized messages from pharmacists and physicians within the EHR. Investigators found that less than half of messages from pharmacists were acknowledged by the prescribing physicians. Among the messages in which pharmacists requested a specific action, physicians completed the action about one-third of the time. Messages were more likely to be acknowledged and acted upon when pharmacists and physicians had an existing working relationship. The authors suggest that EHRs should be better designed to foster interprofessional collaboration. A PSNet perspective highlighted the role of pharmacists in interprofessional care and safety.

Journal Article > Review

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.

Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.

Journal Article > Commentary

Health information technologies: from hazardous to the dark side.

Saunders C, Rutkowski AF, Pluyter J, Spanjers R. J Assoc Inf Sci Technol. 2016;67:1767-1772.

It is important to consider unintended consequences when implementing tools, such has health information technology (IT). This commentary highlights five areas of focus to reduce risks associated with introducing health IT in surgery and recommends systematic training and detailed credentialing to ensure safe use of new technologies.

Journal Article > Review

Electronic tools to support medication reconciliation—a systematic review.

Marien S, Krug B, Spinewine A. J Am Med Inform Assoc. 2017;24:227-240.

This systematic review found that electronic platforms to conduct medication reconciliation frequently lack the needed functionality to reconcile medication lists. The included studies are limited in scope, have insufficient information about the context and environment in which they were implemented, and often omit relevant patient and provider outcomes. This work underscores the need for development of more effective tools for medication reconciliation and additional implementation studies that comprehensively assess their impact.

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