Journal of healthcare risk management : the journal of the American Society for Healthcare Risk Management
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The objective of this study was to describe the frequency, potential harm, and nature of electronic health record (EHR)-related medication errors in intensive care units (ICUs). Using a secondary data analysis of a large database of medication safety events collected in a study on EHR technology in ICUs, we assessed the EHR relatedness of a total of 1622 potential preventable adverse drug events (ADEs) identified in a sample of 624 patients in 2 ICUs of a medical center. Thirty-four percent of the medication events were found to be EHR related. ⋯ Examples of EHR-related events included orders with omitted information and duplicate orders. The list of EHR-related medication errors can be used by health care delivery organizations to monitor implementation and use of the technology and its impact on patient safety. Health information technology (IT) vendors can use the list to examine whether their technology can mitigate or reduce EHR-related medication errors.
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J Healthc Risk Manag · Jul 2016
TeamSTEPPS for health care risk managers: Improving teamwork and communication.
Ineffective communication among the health care team is a leading cause of errors in the patient care setting. Studies assessing training related to communication and teamwork in the clinical team are prevalent, however, teamwork training at the administrative level is lacking. This includes individuals in leadership positions such as health care risk managers. ⋯ Team training has been shown to improve safety culture, patient satisfaction, and clinical outcomes. Including risk managers in training on teamwork, communication, and collaboration can serve to foster a common language among clinicians and management. In addition, a measurement related to implementation in the health care setting may yield insight into the impact of training. Qualitative measurement may allow the researcher to delve deeper into how these health care facilities are using team training interventions.
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J Healthc Risk Manag · Jan 2016
From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective.
The publication of To Err Is Human in 2000, followed by Crossing the Quality Chasm in 2001, marked a watershed in patient safety. The Institute of Medicine (IOM) reports intensified the focus on patient safety and demanded a redesign of the healthcare system to improve quality and safety. Since publication of these reports, the focus has been on improving processes--those methods of healthcare delivery prone to failure and errors. ⋯ In this article, the authors offer a brief review of To Err Is Human and Crossing the Quality Chasm to lay a historical foundation. They then discuss a transition into the focus on diagnostic errors and summarize the latest recommendations from Improving Diagnosis in Health Care. This collated synthesis of 3 powerful IOM reports should guide risk managers and other healthcare personnel as they strive to improve every aspect of healthcare delivery.
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J Healthc Risk Manag · Jan 2014
Electronic health record-related safety concerns: a cross-sectional survey.
Federal electronic health record (EHR)-related initiatives are leading to rapid increases in their adoption. Despite their benefits, EHRs also introduce new risks that can lead to serious safety events. We conducted a Web-based survey of the American Society for Healthcare Risk Management and the American Health Lawyers Association to elicit perceptions regarding the frequency and types of EHR-related serious safety events. ⋯ More than half (53%) of respondents reported at least one EHR-related serious safety event in the previous 5 years, and 10% reported more than 20 events. EHR workflow (63%), user familiarity with the EHR system (63%), and integration with existing systems (59%) were most frequently endorsed as variables associated with EHR-related serious safety events. Because EHR-related safety concerns are underreported, organizations should consider implementing robust measures of EHR safety within their institution as a key step for mitigating these concerns.
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J Healthc Risk Manag · Jan 2014
Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer.
The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events. ⋯ The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes.