Journal of patient safety
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Journal of patient safety · Mar 2014
Shift change handovers and subsequent interruptions: potential impacts on quality of care.
Two statistical surveys in France revealed both widespread dissatisfaction about shift change handovers and the feeling of being frequently disturbed by interruptions. Shift change handovers (SCHs) are being reduced or eliminated in France to reduce staff costs. The objective of our study is to clarify the consequences of short SCHs on efficiency, team function, and quality of care. ⋯ A better sharing of knowledge between the different health-care workers, and especially at the beginning of the work session, could reduce interruptions and potentially improve quality of care.
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Journal of patient safety · Dec 2013
Comparative StudyAutomated adverse event detection collaborative: electronic adverse event identification, classification, and corrective actions across academic pediatric institutions.
Historically, the gold standard for detecting medical errors has been the voluntary incident reporting system. Voluntary reporting rates significantly underestimate the number of actual adverse events in any given organization. The electronic health record (EHR) contains clinical and administrative data that may indicate the occurrence of an adverse event and can be used to detect adverse events that may otherwise remain unrecognized. Automated adverse event detection has been shown to be efficient and cost effective in the hospital setting. The Automated Adverse Event Detection Collaborative (AAEDC) is a group of academic pediatric organizations working to identify optimal electronic methods of adverse event detection. The Collaborative seeks to aggregate and analyze data around adverse events as well as identify and share specific intervention strategies to reduce the rate of such events, ultimately to deliver higher quality and safer care. The objective of this study is to describe the process of automated adverse event detection, report early results from the Collaborative, identify commonalities and notable differences between 2 organizations, and suggest future directions for the Collaborative. ⋯ This work demonstrates the value of EHR-derived data aggregation and analysis in the detection and understanding of adverse events. Comparison and selection of optimal electronic trigger methods and recognition of adverse event trends within and between organizations are beneficial. Automated detection of adverse events likely contributes to the discovery of opportunities, expeditious implementation of process redesign, and quality improvement.
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Journal of patient safety · Dec 2013
Safe use of electronic health records and health information technology systems: trust but verify.
We will provide a context to health information technology systems (HIT) safety hazards discussions, describe how electronic health record-computer prescriber order entry (EHR-CPOE) simulation has already identified unrecognized hazards in HIT on a national scale, helping make EHR-CPOE systems safer, and we make the case for all stakeholders to leverage proven methods and teams in HIT performance verification. ⋯ HIT safety hazards should be taken very seriously, and the need for proven, robust, and regular postdeployment performance verification measurement of EHR system operations in every health-care organization is critical to ensure that these systems are safe for every patient. The TMIT EHR-CPOE flight simulator is a well-tested and scalable tool that can be used to identify performance gaps in EHR and other HIT systems. It is critical that suppliers, providers, and purchasers of health-care partner with HIT stakeholders and leverage the existing body of work, as well as expert teams and collaborative networks to make care safer; and public-private partnerships to accelerate safety in HIT. A global collaborative is already underway incorporating a "trust but verify" philosophy.
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Journal of patient safety · Sep 2013
Randomized Controlled TrialUsing a patient internet portal to prevent adverse drug events: a randomized, controlled trial.
Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and health-care utilization. ⋯ Internet portals have the potential to enhance patient-physician communication. However, additional development is required to demonstrate that such interventions can improve medication safety or health-care utilization.
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Journal of patient safety · Sep 2013
ReviewA new, evidence-based estimate of patient harms associated with hospital care.
Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011. ⋯ The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients' voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.