Improving safety with information technology.
19 Jun 2003-The New England Journal of Medicine (Massachusetts Medical Society)-Vol. 348, Iss: 25, pp 2526-2534
TL;DR: Computerized prescribing by physicians reduces the rate of medication-related errors and systems that automatically page clinicians about serious laboratory abnormalities and remote monitoring of patients in intensive care units also appear promising.
Abstract: Information technology can improve patient safety by preventing errors and facilitating rapid response to adverse events. Computerized prescribing by physicians reduces the rate of medication-related errors. Systems that automatically page clinicians about serious laboratory abnormalities and remote monitoring of patients in intensive care units also appear promising.
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TL;DR: It is found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently, and multiple qualitative and survey methods identified and quantified error risks not previously considered.
Abstract: ContextHospital computerized physician order entry (CPOE) systems are widely
regarded as the technical solution to medication ordering errors, the largest
identified source of preventable hospital medical error. Published studies
report that CPOE reduces medication errors up to 81%. Few researchers, however,
have focused on the existence or types of medication errors facilitated by
CPOE.ObjectiveTo identify and quantify the role of CPOE in facilitating prescription
error risks.Design, Setting, and ParticipantsWe performed a qualitative and quantitative study of house staff interaction
with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed
house staff (N = 261; 88% of CPOE users); conducted 5 focus groups
and 32 intensive one-on-one interviews with house staff, information technology
leaders, pharmacy leaders, attending physicians, and nurses; shadowed house
staff and nurses; and observed them using CPOE. Participants included house
staff, nurses, and hospital leaders.Main Outcome MeasureExamples of medication errors caused or exacerbated by the CPOE system.ResultsWe found that a widely used CPOE system facilitated 22 types of medication
error risks. Examples include fragmented CPOE displays that prevent a coherent
view of patients’ medications, pharmacy inventory displays mistaken
for dosage guidelines, ignored antibiotic renewal notices placed on paper
charts rather than in the CPOE system, separation of functions that facilitate
double dosing and incompatible orders, and inflexible ordering formats generating
wrong orders. Three quarters of the house staff reported observing each of
these error risks, indicating that they occur weekly or more often. Use of
multiple qualitative and survey methods identified and quantified error risks
not previously considered, offering many opportunities for error reduction.ConclusionsIn this study, we found that a leading CPOE system often facilitated
medication error risks, with many reported to occur frequently. As CPOE systems
are implemented, clinicians and hospitals must attend to errors that these
systems cause in addition to errors that they prevent.
2,031 citations
TL;DR: Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
Abstract: ContextDelayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events.ObjectivesTo characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process.Data SourcesMEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies.Study SelectionObservational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18).Data ExtractionData from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer.Data SynthesisDirect communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents.ConclusionsDeficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.
1,886 citations
Additional excerpts
...Patient or family counseling 92 (92-97)19,26,33 91 (90-92)19,33...
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...5 (43-90)26,28,32,61,63 52 (51-77)20,21,28,59...
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...Available in hospital medical record 82 (77-85)16,30,67 85 (82-93)30,68,69...
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...Within 1 wk† 53 (30-94)19,20,25,26,28,43,61,63 14....
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...At all 89 (39-99)19,22,25,26,28,43,61 75 (27-95)19,21,28,68,69...
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TL;DR: Recommendations from the ACE and the ADA generally endorsed tight glycemic control in critical care units and for patients in general medical and surgical units, where RCT evidence regarding treatment targets was lacking, glycemic goals similar to those advised for outpatients were advocated.
Abstract: People with diabetes are more likely to be hospitalized and to have longer durations of hospital stay than those without diabetes. A recent survey estimated that 22% of all hospital inpatient days were incurred by people with diabetes and that hospital inpatient care accounted for half of the 174 billion USD total U.S. medical expenditures for this disease (1). These findings are due, in part, to the continued expansion of the worldwide epidemic of type 2 diabetes. In the U.S. alone, there are ∼1.6 million new cases of diabetes each year, with an over all prevalence of 23.6 million people (7.8% of the population, with one-fourth of the cases remaining undiagnosed). An additional 57 million American adults are at high risk for type 2 diabetes (2). Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients (3–6).
There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) have suggested that intensive treatment of hyperglycemia improved hospital outcomes (5–8). In 2004, this evidence led the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE), in collaboration with the American Diabetes Association (ADA) and other medical organizations, to develop recommendations for treatment of inpatient hyperglycemia (9). In 2005, the ADA added recommendations for treatment of hyperglycemia in the hospitalto itsannual Standards of Medical Care (10). Recommendations from the ACE and the ADA generally endorsed tight glycemic control in critical care units. For patients in general medical and surgical units, where RCT evidence regarding treatment targets was lacking, glycemic goals similar to those advised for outpatients were advocated (9, …
1,471 citations
TL;DR: Improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals.
Abstract: Five years ago, the Institute of Medicine (IOM) called for a national
effort to make health care safe. Although progress since then has been slow,
the IOM report truly “changed the conversation” to a focus on
changing systems, stimulated a broad array of stakeholders to engage in patient
safety, and motivated hospitals to adopt new safe practices. The pace of change
is likely to accelerate, particularly in implementation of electronic health
records, diffusion of safe practices, team training, and full disclosure to
patients following injury. If directed toward hospitals that actually achieve
high levels of safety, pay for performance could provide additional incentives.
But improvement of the magnitude envisioned by the IOM requires a national
commitment to strict, ambitious, quantitative, and well-tracked national goals.
The Agency for Healthcare Research and Quality should bring together all stakeholders,
including payers, to agree on a set of explicit and ambitious goals for patient
safety to be reached by 2010.
1,296 citations
Cites background from "Improving safety with information t..."
...The results achieved in implementing 12 practice changes are presented in the TABLE.(4,28-35) If these results were replicated nationwide, the impact would be substantial....
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...The results achieved in implementing 12 practice changes are presented in the TABLE.4,28-35 If these results were replicated nationwide, the impact would be substantial....
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TL;DR: It is found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently, in addition to errors that they prevent.
Abstract: CONTEXT
Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE.
OBJECTIVE
To identify and quantify the role of CPOE in facilitating prescription error risks.
DESIGN, SETTING, AND PARTICIPANTS
We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders.
MAIN OUTCOME MEASURE
Examples of medication errors caused or exacerbated by the CPOE system.
RESULTS
We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction.
CONCLUSIONS
In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.
937 citations
References
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01 Jan 2000
TL;DR: Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.
Abstract: Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.
16,469 citations
"Improving safety with information t..." refers background in this paper
...In contrast, relatively little effort has been targeted at the perfection of operational systems, which are partly responsible for the well-documented problems with medical safety.(1) If medicine is to achieve major gains in quality, it must be transformed, and information technology will play a key part,(2) especially with respect to safety....
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...In the past decade, the risk of harm caused by medical care has received increasing scrutiny.(1) The growing sophistication of computers and software should allow information technology to play a vital part in reducing that risk — by streamlining care, catching and correcting errors, assisting with decisions, and providing feedback on performance....
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TL;DR: Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.
Abstract: Crossing the Quality Chasm identifies and recommends improvements in six dimensions of health care in the U.S.: patient safety, care effectiveness, patient-centeredness, timeliness, care efficiency, and equity. Safety looks at reducing the likelihood that patients are harmed by medical errors. Effectiveness describes avoiding over and underuse of resources and services. Patient-centeredness relates both to customer service and to considering and accommodating individual patient needs when making care decisions. Timeliness emphasizes reducing wait times. Efficiency focuses on reducing waste and, as a result, total cost of care. Equity looks at closing racial and income gaps in health care.
15,046 citations
TL;DR: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable and prevention strategies should target both stages of the drug delivery process.
Abstract: Objectives. —To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. Design. —Prospective cohort study. Participants. —All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. Main Outcome Measures. —Adverse drug events and potential ADEs. Methods. —Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. Results. —Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. Conclusion. —Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process. (JAMA. 1995;274:29-34)
3,120 citations
"Improving safety with information t..." refers background in this paper
...The use of computers can also reduce the frequency of errors of calculation, a common human failing.(29) Such tools can be used on demand — for example, by a nurse in the calculation of an infusion rate....
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TL;DR: Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.
Abstract: Context.—Adverse drug events (ADEs) are a significant and costly cause of injury
during hospitalization.Objectives.—To evaluate the efficacy of 2 interventions for preventing nonintercepted
serious medication errors, defined as those that either resulted in or had
potential to result in an ADE and were not intercepted before reaching the
patient.Design.—Before-after comparison between phase 1 (baseline) and phase 2 (after
intervention was implemented) and, within phase 2, a randomized comparison
between physican computer order entry (POE) and the combination of POE plus
a team intervention.Setting.—Large tertiary care hospital.Participants.—For the comparison of phase 1 and 2, all patients admitted to a stratified
random sample of 6 medical and surgical units in a tertiary care hospital
over a 6-month period, and for the randomized comparison during phase 2, all
patients admitted to the same units and 2 randomly selected additional units
over a subsequent 9-month period.Interventions.—A physician computer order entry system (POE) for all units and a team-based
intervention that included changing the role of pharmacists, implemented for
half the units.Main Outcome Measure.—Nonintercepted serious medication errors.Results.—Comparing identical units between phases 1 and 2, nonintercepted serious
medication errors decreased 55%, from 10.7 events per 1000 patient-days to
4.86 events per 1000 (P=.01). The decline occurred
for all stages of the medication-use process. Preventable ADEs declined 17%
from 4.69 to 3.88 (P=.37), while nonintercepted potential
ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention
combined, the team intervention conferred no additonal benefit over POE.Conclusions.—Physician computer order entry decreased the rate of nonintercepted
serious medication errors by more than half, although this decrease was larger
for potential ADEs than for errors that actually resulted in an ADE.
2,073 citations
"Improving safety with information t..." refers background in this paper
...In one controlled trial involving inpatients, the implementation of a computerized application for order entry by physicians — which improves communication, makes knowledge accessible, includes appropriate constraints on choices of drugs, routes, frequencies, and doses, helps with calculations, performs real-time checks, and assists with monitoring — resulted in a 55 percent reduction in serious medication-related errors.(8) In a further study, which evaluated serial improvements to this application with the addition of higher levels of support for clinical decisions (e....
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...Data now show that information technology can reduce the frequency of errors of different types and probably the frequency of associated adverse events.(7,8,9,10,11,12,13,14,15,16,17,18) The main classes of strategies for preventing errors and adverse events include tools that can improve communication, make knowledge more readily accessible, require key pieces of information (such as the dose of a drug), assist with calculations, perform checks in real time, assist with monitoring, and provide decision support....
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TL;DR: It is simply not scientifically possible to estimate current national iatrogenic injury and death rates based solely on the Harvard Medical Practice Study's (MPS) decade-old sample of patient discharge records, which included only one state during just 1 year (1984).
Abstract: Objective. —To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. Design. —Systems analysis of events from a prospective cohort study. Participants. —All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Main Outcome Measures. —Errors, proximal causes, and systems failures. Methods. —Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. Results. —During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. Conclusions. —Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely. ( JAMA . 1995;274:35-43)
1,909 citations