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PubMed2005

Systems failure in hospitals--using Reason's model to predict problems in a prescribing information system.

Both hospitals and hospital patients are bearing a massive cost as a result of the occurrence of medication prescribing errors in the public health system (Bates, D., et al. J. Am. Med. Inform. Assoc. 8(4):299-308, 2001; Lombardi, T. Medscape Pharm. Online J. 02(1), 2001; Roberts, M., and Stokes, J. eMed. J. Aust. 168:317-318, 1998). Consequently, it is important to examine and address the possible causes of this problem. In this paper we suggest that poor information systems may be a contributing factor in the occurrence of these errors. We research this issue in an HIV ward of a large public hospital through interviews and a survey instrument. We find that in a significant number of instances prescribing errors are linked to situations where information is unavailable or inaccessible. This link, between problems in information delivery and prescribing errors, is a link whose extent has not been measured previously. It is, however, a link which exposes all stakeholders in the hospital system, the patient, the clinicians, the hospital, and governments funding prescription medications, to possible loss and damage and indicates a need for the implementation of more effective systems in this area. We use Reason's model for predicting systems error (Vincent, C. BMJ 316:1154-1157, 1998) as a tool to suggest that prescribing errors have an increased likelihood of occurring if one or more of the types of failure identified in the model are present in the existing prescribing information delivery process in the hospital. While Reason's model has been applied in a medical context, it has not been previously applied to errors which result from information systems failure. We feel that applying it in this way may shed some light on the causes of prescribing error.

HIV Infections↗
PubMed1994

Semantic integration of information in a physician's workstation.

Patient care is an information-intensive activity, yet physicians have few tools to effectively access and manage patient data. We studied physicians' information needs in an outpatient clinic, and developed a prototype physician's workstation (PWS) to address those needs. The PWS provides integrated access to patient information and uses embedded domain knowledge to enhance the presentation of clinical information to the physician. All the applications in the PWS share a common patient context, defined by the state of the internal patient model--semantic integration. Relevant data are presented together and higher-order alerts are generated by combining notable events with relevant data from the patient context. Semantic integration allows us to present and to operate on all patient data in a given patient's context, significantly enhancing the effectiveness with which information is presented to the physician.

Computer Communication Networks↗
PubMed1986

Diuretic-induced laboratory abnormalities that predict ventricular ectopy.

In order to determine which of the many diuretic-induced laboratory changes might be associated with an increased risk of ventricular ectopy (VE), we performed logistic regression analyses of patient data from a large computerized medical record system. Study variables included serum Ca2+, K+, Cl-, HCO-3, glucose, cholesterol, albumin, uric acid, and hematocrit. Controlling variables included race, use of diuretics, blood pressure, smoking history, age, and weight. (In one analysis we also included cardiac drug history and evidence of pre-existing cardiovascular disease). Separate analyses were performed for males and females. For the retrospective cohort-like design, we analyzed data for 9561 patients with complete data. For the case-control design we analyzed data from 4786 patients. Diuretic usage predicted ventricular ectopy in women, but not men. Serum uric acid and hematocrit were the only significant laboratory predictors of ventricular ectopy in each of the four analyses. Abnormalities in these variables might provide an explanation for the greater incidence in sudden (and presumably arrhythmic) deaths reported in MRFIT study patients with mild hypertension.

Arrhythmias, Cardiac↗
PubMedDate not supplied

The paper-based patient record: is it really so bad?

In a recent review of literature, a committee of the American Institute of Medicine found much support of the weakness of the paper-based patient record. Inspired by these results, a local survey was held among practicing clinicians to test, whether they could subscribe the Committee's conclusions. The clinicians turned out to be far more positive about the quality of the paper-based patient record. Possible explanations for this discrepancy are discussed, as well as the question, whether the results of the Committee's review may be used as a basis for the implementation of computer-based patient records.

Attitude of Health Personnel↗
PubMed2005

Reduction of adverse drug events and medication errors in a community hospital setting.

Keys to success in reducing ADEs have included the support of administrative leaders through their visibility and emphasis on safety as an organizational priority, and financial support for safety projects. Administrative participation was also helpful in promoting safety efforts through the reinforcement of expectations when progress was sluggish. The use of rapid cycle change provided enough early success to serve in motivating staff to push ahead. It allowed staff the opportunity to analyze changes, make adjustments, and retest on a slightly larger scale. Other key success factors included the motivation of teams through continual sharing of progress and success stories; celebrations for achievements are held routinely. As an organization, SJMC has shared its success strategies with other organizations and promoted networking with other organizations to determine what strategies have worked elsewhere. This is helpful as it prevents time from being wasted on solutions that have been tried without success. Within the OSF Healthcare System, the following phrase has been adopted in regard to patient safety, "Safety is like peeling an onion; the more you look, the more you find, and each layer makes you cry."

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Development and evaluation of an integrated pharmaceutical education system.

There is increasing evidence that patient safety can be improved by the introduction of an integrated computer-based medical care system in hospital settings. In this paper, we describe an integrated pharmaceutical information system (IPIS) in which a patient's profile including his/her medication records and prescriptions are collected from physician order entry systems and pharmaceutical systems along with the history of patient care in the hospital. Based on an individual patient's profile the IPIS can provide pharmaceutical education information specifically to meet the patient's needs. The IPIS has been developed and installed at Taipei Medical University Wanfang Hospital (TMUWFH) since July 2002. Evaluation of the system showed that it can help patients to effectively acquire drug information. This enables them to have a much better understanding of the pharmacological properties of the medicines they are taking, including adverse drug reactions and side-effects. In our opinion the system has the potential to improve both patient safety and treatment outcomes.

Drug Information Services↗
PubMed2005

Differing faculty and housestaff acceptance of an electronic health record.

In order to determine whether differences exist between housestaff and faculty physician acceptance of an electronic health record system, we conducted a written survey of attitudes towards new electronic medical record at the University of Illinois at Chicago. We surveyed 330 faculty and housestaff physicians. User acceptance of the EHR was high for both faculty physicians and housestaff. An amount of 88.0% of the housestaff and 64.7% of the faculty preferred the EHR over a paper record. Although both housestaff and faculty acceptance of an EHR was high, housestaff showed greater approval ratings than faculty. Central to acceptance of an EHR is conservation of physician time, including improving system speed, reducing time spent waiting for a computer to become available, and minimizing time spent documenting care.

Adult↗
PubMed2006

OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record.

In studies on success and failure of ICT applications in health care, the 'context' is often used to explain the failure of a system and seldom to explain the success of a system. Science and Technology Studies (STS) have showed that for understanding success and failure of phenomena, one has to take a symmetrical approach and thus use the same concept for analyzing success and failure. In this article we analyze the success of OZIS, a communication protocol that makes it possible for pharmacists to exchange medication data by sharing a regionally accessible electronic medication record. Though OZIS serves a common goal - reducing medication errors - the stakeholders that are involved also have other, competing, interests. By focussing on the context and more specifically the interests of the stakeholders, we will show how the success of OZIS can be explained. By doing this, we will also show that this context is highly dynamic and that continuously changing incentives and constraints within the context lead to both facilitating and threatening the success of OZIS.

Access to Information↗
PubMed2007

Electronic health record implementation in community nursing homes.

INTRODUCTION: The Electronic Health Record (EHR) is being advocated as a tool to improve patient care. Nationwide initiatives are under way to determine how to implement EHR. To date, community nursing homes have not been involved in that effort. Many reasons, including multiple providers in a home, physical structure of a facility, multiple facilities, high costs of implementation, and maintenance of an EHR, hinder efforts to establish such a record in a nursing home. Convinced that an EHR would improve resident care, we undertook a project to establish an EHR in 11 community nursing homes. METHODS: Boston University Geriatric Services and Boston Medical Center partnered with 11 community nursing homes in the Boston, MA, area to introduce GE Centricity as the medical provider's medical record for the residents under the care of this medical practice. This effort included allowing the software to be used at various sites, providing hardware, and establishing Internet connectivity. RESULTS: All 11 of the nursing homes served by Boston University Geriatric Services have been connected to the system. DISCUSSION: It is possible to establish an EHR in a diverse, unrelated group of nursing homes. This has allowed for improved communication between providers, consultants, hospital, and nursing home staff.

Academic Medical Centers↗
PubMed1995

Is obesity a barrier to physician screening for cervical cancer?

OBJECTIVE: To determine if obese and morbidly obese women are as likely to receive Papanicolaou (Pap) smears as nonobese women. PATIENTS AND METHODS: A secondary analysis was conducted of data collected during a prospective, controlled trial of computer-generated reminders to improve preventive care. The site was a large, academic general medicine practice providing primary care to an urban population at a university-affiliated municipal teaching hospital. Data were analyzed from 15 faculty and 77 resident physicians who delivered care to 1,321 women who were eligible for Pap smears. Patient data were obtained from a computerized medical record system. RESULTS: Outcomes were physician reports of Pap smear performance and reasons for nonperformance of Pap smears in eligible women. Pap smear performance was 21% for nonobese women, 20% for obese women, and 20% for morbidly obese women (P = NS). After adjusting for age and race, odds ratios for omission of Pap smear were 1.20 for both obese (95% confidence interval [CI] 0.86 to 1.67; P = NS) and morbidly obese women (95% CI, 0.58 to 2.47; P = NS). A significant dose-response relationship was found between increasing patient weight and physician responses that the Pap smear was delayed due to patient's acute illness, vaginitis, or menstruation (odds ratios [OR] 1.73 for obese, OR 4.59 for morbidly obese women; P < 0.005). CONCLUSIONS: In our general medicine practice, obesity does not appear to be associated with less Pap smear performance. Physicians are more likely to report delaying obese patients' Pap smears due to acute illness, vaginitis, or menstruation.

Female↗
PubMed2004

The perils of CPOE.

Explore the source record for details and available documents.

Decision Support Systems, Clinical↗
PubMed1999

Development of a chronic disease indicator score using a Veterans Affairs Medical Center medication database. IMPROVE Investigators.

OBJECTIVE: Develop a chronic disease index that approximates the number of chronic diseases a patient has using a medication database. METHODS: An expert panel determined whether specific medication classes could be indicative of a chronic disease. Those classes identified were incorporated into a computer program and then used to screen the medication records of 246 randomly selected patients to estimate the number of chronic diseases present in each patient. This number was designated as the chronic disease index (CDI). The CDI was then validated against chart review. The CDI and a measure of disease severity, the chronic disease score (CDS) also were compared. The sensitivity and specificity of the computer program was analyzed for seven common chronic diseases. RESULTS: The expert panel designated 54 drug classes containing medications used to treat chronic diseases. The CDI correlated moderately with the number of chronic diseases found via chart review (r = 0.65; P = 0.001) and highly with the CDS (r = 0.81; P = 0.001). The index predicted the presence of three common diseases with a sensitivity of > or = 75%, and of six common diseases with a specificity of > or = 75%. CONCLUSIONS: The CDI correlates moderately well with the actual number of chronic disease states present. This tool may be useful for researchers when trying to identify patients with specific diseases and also for risk adjustment.

Chronic Disease↗
PubMed2002

Development and evaluation of VIE-PNN, a knowledge-based system for calculating the parenteral nutrition of newborn infants.

Calculating the daily changing composition of parenteral nutrition for small newborn infants is troublesome and time consuming routine work in neonatal intensive care. The task needs expertise and experience and is prone to inherent calculation errors. We designed VIE-PNN (Vienna Expert System for Parenteral Nutrition of Neonates), a knowledge-based system (KBS) in order to reduce daily routine work and calculation errors. VIE-PNN was redesigned several times because the clinicians accepted the system only when it saved time. The most recent version of VIE-PNN uses an Hypertext Markup Language (HTML)-based client-server architecture and is integrated into the intranet of the local patient data management system. Since more than 3 years all parenteral nutrition plans are calculated using VIE-PNN. Evaluating the system's performance and the users contentedness, we compared 50 nutrition plans calculated in parallel using VIE-PNN or a hand-held calculator, retrospectively analyzed more than 5000 nutrition plans stored in VIE-PNNs database and evaluated a user questionnaire. Nutrition plans were calculated in a mean time of 2.4 versus 7.1min using VIE-PNN or the hand-held calculator. Errors and omissions in the nutrition plans were detected in 22% versus 56% and errors in the VIE-PNN's plans occurring only with interactively changed values. Reviews of stored plans show that a mean of 4 out of 16 parameters were interactively changed. VIE-PNN was well accepted. Most important reasons for the successful operation of VIE-PNN in the daily routine work were time savings and robustness of the system.

Artificial Intelligence↗
PubMed2002

Impact of a physician's order entry (POE) system on physicians' ordering patterns and patient length of stay.

OBJECTIVE: To investigate the impact of a physician's order entry (POE) system on physicians' ordering patterns and patient length of stay. DESIGN: Prospective time series study at pre-POE, 3 months and 6 months after POE at a tertiary teaching hospital in Korea. The study period was from June 1999 to May 2000. MEASUREMENTS: The number of orders (doctor's, PRN, medication, changed, canceled orders), number of tests (complete blood count, chemistry, chest X-ray, stat laboratory, serum electrolytes tests), appropriateness and length of patient stay were measured through chart review of 171 in-patients (liver disease, renal disease, gastrectomy, simple mastectomy). RESULTS: The number of doctors' orders, PRN, and medication orders significantly increased after POE. The numbers of changed and canceled orders were not significantly different between pre- and post-POE. The number of stat lab tests significantly decreased after POE. There was no change in appropriateness of patients' hospital stay between pre- and post-POE. Length of stay significantly decreased (P=0.049). CONCLUSION: POE contributed to improving the quality of care in two ways: improvement of auditability by recording the medical services for patients in more precise and transparent manner, and more appropriate utilization of resources by decreasing the number of stat diagnostic tests and length of stay.

Analysis of Variance↗
PubMed2004

Improving recognition of depression in primary care: a study of evidence-based quality improvement.

BACKGROUND: Depression's high prevalence and large amount of potentially modifiable morbidity make it an excellent candidate for quality improvement (QI) techniques. Yet there is little evidence on how to promote adherence to evidence-based guidelines. A locally run research and QI project that was part of a larger National Institute of Mental Health-funded study to implement depression guidelines was implemented by a primary care team at a Department of Veterans Affairs (VA) ambulatory care center in 1997 and 1998. DEVELOPMENT OF THE QI INTERVENTION: The plan to improve screening and recognition entailed systematically screening all patients attending the primary care clinic; sending computer reminders to clerical staff, nursing assistants, and primary care providers; and auditing team performance with monthly feedback. RESULTS: Once the intervention was in place, nearly all patients were screened. The primary care provider documented the assessment of whether a patient was depressed for nearly all patients who screened positive. Few resources were needed to maintain the project once it was implemented. DISCUSSION: An evidence-based QI intervention led to profound and lasting changes in primary care providers' recognition of depression or depressive symptoms. The QI implementation continued for one year after the intervention's end, but a new VA computerized medical record system uses similar computer-generated reminders.

Data Collection↗
PubMed2003

User acceptance of an anaesthesia information management system.

BACKGROUND AND OBJECTIVE: This paper describes the user acceptance of an anaesthesia information management system at the University Hospital in Giessen, Germany, after 5 yr of routine use. METHODS: A questionnaire with 75 items was distributed to all anaesthesiologists and anaesthetic nurses of the Department of Anaesthesiology. The questions were answered anonymously on a five-point Likert scale. RESULTS: The return rate was 60% (44 physicians and 24 nurses). The results indicated that the system generally met user expectations. The respondents thought that electronic record keeping improved the quality of their work, and they did not want to switch back to paper records. Problems arose with hardware placement and software features, e.g. coding tools for diagnoses and type of surgery. The perceived quality of training strongly influenced user acceptance. CONCLUSIONS: Despite the deficits revealed by the survey, the respondents did not want to switch back to manual record keeping. A structured user survey is a useful tool for the development, adaptation and implementation of an anaesthesia information management system. A training strategy that takes the needs of the users into account is recommended.

Adult↗