Health IT and Patient Safety: Building Safer Systems for Better Care

Chou, David

doi:10.1001/jama.308.21.2282-a

Cited by 71 publications

(20 citation statements)

References 185 publications

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“…With over 26.1% (range: 16.0%–53.6%) of medication orders initiated using a CPOE system in acute care hospitals in the USA ,14 the importance of devising effective mechanisms to identify, characterise and track medication ordering errors is of significant concern. The value of recording and tracking medication errors has been highlighted in an Institute of Medicine (IOM; now, the National Academy of Medicine) committee report, Health IT and Patient Safety: Building Safer Systems for Better Care,15 and in the 2014 US Food and Drug Administration Safety and Innovation Act 16. Furthermore, medication safety experts have emphasised the ‘worrisome lack of effort to learn from medication ordering errors’ and characterised the current state of unsafe medication ordering practices to be ‘still a work in progress’ 17.…”

Section: Background and Significancementioning

confidence: 99%

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

et al. 2017

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We demonstrated that voided orders effectively captured medication ordering errors. The mismatch between clinician-CPOE-selected and the chart review-based reasons for error emphasises the need for developing standardised operational descriptions for medication ordering errors. Such standardisation can help in accurately identifying, tracking, managing and sharing erroneous orders and their root contributors between healthcare institutions, and with patient safety organisations.

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Section: Background and Significancementioning

confidence: 99%

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

et al. 2017

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“…1 Muitos estudos abordam erros com medicamentos. [2][3][4] Entretanto, outros tipos de eventos também têm sido estudados e evidenciam os riscos relacionados a procedimentos e processamento de materiais para uso em saúde.…”

Section: Introductionunclassified

Incidentes de segurança ocorridos com pacientes durante o cuidado de enfermagem

Hoefel

Echer

Lucena

et al. 2017

Rev Epidemiol Control Infect

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Exceto onde especificado diferentemente, a matéria publicada neste periódico é licenciada sob forma de uma licença Creative Commons -Atribuição 4. Background and Objectives:Patient safety is a worldwide concern that has been highlighted in recent years and its study subsidizes preventive actions. The objective was to analyze patient safety incidents that occurred during nursing care. Methods: This was a retrospective, descriptive-exploratory documentary study carried out at a university hospital in southern Brazil. The documents related to patient safety incidents occurred during nursing care at the institution were classified and analyzed. Results: A total of 82 incidents were analyzed, of which 43 (52%) were classified as adverse events and 39 (48%) as incidents without harmful consequences. In 53 (64%) cases, the causes of the incidents occurred due to errors, 14 (17%) due to violations and 15 (18%) due to system failure. Incidents related to technical procedures were responsible for 67 (82%) occurrences, and adverse events occurred in 38 (57%) of them. Conclusion: Incidents causing both adverse events and those with no harmful consequences during care were identified, mostly caused by errors, followed by violations or system failures.

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“…In reality, the literature is limited, as demonstrated in a recent systematic review [ 6 ] of eHealth technologies and their impact on the quality and safety of healthcare, which concluded that there is a gap between the proposed and empirically evidenced benefits of eHealth technologies. In addition, there is little consideration given in existing literature to potential negative effects of these systems on patient safety, with existing evidence under-cited and predominately from the U.S whose health service has different economic, organisational and structural foundations from the UK [ 7 – 11 ]. In their review [ 6 ], Black et al provided some discussion into this and suggested that the lack of evidence may be due to publication bias, with potential conflicts of interest making it particularly difficult to publish negative findings [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

The impact of electronic records on patient safety: a qualitative study

Clarke

Adamson

Watt

et al. 2016

BMC Med Inform Decis Mak

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BackgroundOur aim was to explore NHS staff perceptions and experiences of the impact on patient safety of introducing a maternity system.MethodsQualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives, health care assistants), staff grades (consultant and midwife grades) and wards within a maternity unit. Participants represented a single maternity unit at a NHS teaching hospital in the North of England. Interviews were conducted during the first 12 months of the system being implemented and were analysed thematically.ResultsParticipants perceived there to be an elevated risk to patient safety during the system’s implementation. The perceived risks were attributed to a range of social and technical factors. For example, poor system design and human error which resulted in an increased potential for missing information and inputting error.ConclusionsThe first 12 months of introducing the maternity system was perceived to and in some cases had already caused actual risk to patient safety. Trusts throughout the NHS are facing increasing pressure to become paperless and should be aware of the potential adverse impacts on patient safety that can occur when introducing electronic systems. Given the potential for increased risk identified, recommendations for further research and for NHS trusts introducing electronic systems are proposed.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0299-y) contains supplementary material, which is available to authorized users.

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Health IT and Patient Safety: Building Safer Systems for Better Care

Cited by 71 publications

References 185 publications

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

Incidentes de segurança ocorridos com pacientes durante o cuidado de enfermagem

The impact of electronic records on patient safety: a qualitative study

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