28 research outputs found

    A Systematic Review Of The Types And Causes Of Prescribing Errors Generated From Using Computerized Provider Order Entry Systems in Primary and Secondary Care

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    Objective To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. Materials and Methods We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. Results A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users’ work processes, and clinical decision support systems. Displaying an incomplete list of a patient’s medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users’ misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. Discussion and Conclusions Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users’ workflow expectations

    An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

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    Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area

    Toward Timely Data for Cancer Research: Assessment and Reengineering of the Cancer Reporting Process

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    Background Cancer registries systematically collect cancer-related data to support cancer surveillance activities. However, cancer data are often unavailable for months to years after diagnosis, limiting its utility. Objective The objective of this study was to identify the barriers to rapid cancer reporting and identify ways to shorten the turnaround time. Methods Certified cancer registrars reporting to the Indiana State Department of Health cancer registry participated in a semistructured interview. Registrars were asked to describe the reporting process, estimate the duration of each step, and identify any barriers that may impact the reporting speed. Qualitative data analysis was performed with the intent of generating recommendations for workflow redesign. The existing and redesigned workflows were simulated for comparison. Results Barriers to rapid reporting included access to medical records from multiple facilities and the waiting period from diagnosis to treatment. The redesigned workflow focused on facilitating data sharing between registrars and applying a more efficient queuing technique while registrars await the delivery of treatment. The simulation results demonstrated that our recommendations to reduce the waiting period and share information could potentially improve the average reporting speed by 87 days. Conclusions Knowing the time elapsing at each step within the reporting process helps in prioritizing the needs and estimating the impact of future interventions. Where some previous studies focused on automating some of the cancer reporting activities, we anticipate much shorter reporting by leveraging health information technologies to target this waiting period

    Evaluating information flow in medication management process in Australian acute care facilities: A multi-professional perspective

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    Over the years, various interventions have been introduced to improve the medication management process. While these interventions have addressed some aspects predisposing the process to inefficiencies, significant gaps are still prevalent across the process. Studies have suggested that the goal of optimal medication therapy is achievable when information flow integrates across the various medication management process phases, stakeholders and departments involved as the patient moves through the process. To provide a cross-sectional view of the process, this study utilised a systemic philosophy to evaluate the information flow integration across the process. The research approach adopted for this study takes a positivist paradigm, which is guided by the cause and effect (causality) belief. It explored numeric measures to evaluate the relationship between constructs that assessed information flow principles (accessibility, timeliness, granularity and transparency) within the medication process and the information integration. The research design was cross-sectional and analytical, and this ensures that findings are relevant to current situations across the Australian healthcare system. Data for this research was collected using an online self-administered survey and the data assessed information flow principles and technologies used in the medication management process. There were 88 participants in this study, including doctors, nurses and pharmacists. The questions and responses were coded for analysis and data analysis techniques used were frequency analysis, Pearson’s chi-square test and multivariate analysis. Findings from this study indicates that the constructs evaluating accessibility, transparency and granularity had moderate associations with the information integration in the medication management process. Further analysis highlighted accessibility as a significant principle in explaining an increase or decrease in information integration in the medication management process. The accessibility construct referring to information retrieval was significant across the two tests conducted. Accessibility is directly related to information sharing and the assessment and monitoring and evaluation phases in the medication management process were identified as having the highest challenges with information sharing. Furthermore, the hybrid (electronic and paper) channel was preferred to support information integration in the medication management process by the participants. Among the technologies evaluated for the medication process, computer-provider-order-entry was found to be statistically significant in explaining an increase in information integration. Overall, results from this study suggest that interventions for the medication management process in Australian acute care facilities should be directed towards improving accessibility, specifically information retrieval and the sharing of information with emphasis on the assessment and monitoring phases. Implementing strategies to address the gaps identified from this research can improve information integration across the process and thereby reducing medication errors, and improving patient care management. Furthermore, the technology adoption across the process highlights that technology adoption across participants’ facilities remains a challenge in Australia

    System-related errors associated with the long-term use of electronic medication management

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    Background: Electronic medication management (EMM) systems can facilitate system-related errors; errors that were less likely with the use of paper-based medication charts. Little is known about the types of system-related errors that persist or emerge with routine system use. This thesis aimed to identify and classify long-term system-related errors, determine contributing factors and compare errors over time. Methods: Research was conducted at three hospitals with the same EMM system in place for different durations. A narrative review was followed by mixed methods research, including an analysis of EMM-related incident reports, interviews with stakeholders and a review of documents detailing EMM system enhancements at the three sites. Long-term system-related errors were examined in terms of error types, contributing factors, consequences, and strategies for detection and mitigation. Analysis of each data source considered the element of time since EMM system implementation. Results: System-related errors were found to persist with long-term EMM system use. Factors related to the EMM system design, user and organisation contributed to system-related errors in varying degrees over time, however certain factors were consistently associated with errors. System-related errors resulted in medication errors, but also impacted the user, and documentation within the EMM system. Detection of system-related errors relied heavily on clinicians, while mitigation strategies targeted the EMM system and the context in which the system was used. Conclusion: This program of research highlighted how system-related errors develop over time. The findings emphasise that system-related errors result from a combination of different factors, and therefore mitigation strategies should be multilayered. Future research should investigate the effectiveness of interventions aimed at minimising system-related errors, particularly as EMM systems are increasingly implemented and improved

    Information in Healthcare: An Ethnographic Analysis of a Hospital Ward.

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    This dissertation uses psychosocial information as a lens to examine doctors’ and nurses’ information use and documentation practice. It draws on a 17-month ethnographic study, in-depth analysis of medical records, and semi-structured interviews to investigate clinicians’ documentation behaviors. This investigation produced several findings. First, adopting a Computerized Prescriber Order Entry (CPOE) system can cause loss of written psychosocial information as nurses reluctantly make certain data permanent. Second, CPOE adoption may create information gaps in nurses’ knowledge about patients. Third, while use of CPOE systems can successfully reduce medication errors, it removes discretion, nuance, temporality, and human interpretation from paper order practice to rigidly fit machine requirements. This can redistribute power and responsibility. Fourth, although doctors document psychosocial information in an electronic health records (EHR) system, they record it selectively and a medicalized viewpoint governs this selection process. As a result, missing patient representations affect work activities and patient care. This study has broad implications for medical informatics. It cautions against casual computerization. Many well-intentioned efforts to computerize paper records assume the transition only changes media, but this study shows how social agreement and institutional arrangement around documenting patient psychosocial information can be shattered by this transition. It also suggests that efforts should be made to respect local knowledge and practice in the computerization of medical information. The findings also suggest a need for a dual conceptualization of EHR as both a representation of medical work (process-oriented) and patients (patient-centered, as to consider information reuse from a long-term perspective). This study also seeks to extend theories of boundary objects. It reveals that the nature of a boundary object can change when that object and the practice surrounding its use are both automated. It proposes to conceptualize process-oriented systems, such as CPOE or EHR, as information assemblages, which embed multiple information objects, heterogeneous practices, work processes, and coordination mechanisms. Furthermore, the analysis of this study uses a stack of conceptual framings: boundary object, extended boundary object, assembled object, collection, and assemblage, and argues these framings together serve to understand computerized records in a medical setting far better than can any single concept.Ph.D.InformationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/78940/1/xmzhou_1.pd

    An Analysis of the North Carolina Nursing Home Polypharmacy Initiative

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    This dissertation is an evaluation of the North Carolina Polypharmacy Initiative (Initiative). The Initiative was a demonstration project that remunerated nursing home consultant pharmacists for value-added drug regimen reviews using a claims-generated patient profile that flagged targeted drugs and drug classes for review. Shewhart's PDSA (Plan-Do-Study-Act) cycle is used as the framework to guide this evaluation. The Initiative brought about three distinct PDSA cycles throughout its history. The first was the pilot project, and the second was a statewide endeavor, while the third continues through other programs and settings in North Carolina. It is the goal of this dissertation to inform the planning stage of future PDSA cycles of pharmacist services in nursing home settings. Three formal evaluations of the initiative were conducted. The first evaluation, a before-after without comparison group study found a per member per month (PMPM) drug cost savings of 30.33duetoinitiativeactivities.Thesecond,abefore−afterwithcomparisongroupstudyfoundaPMPMdrugcostsavingsof30.33 due to initiative activities. The second, a before-after with comparison group study found a PMPM drug cost savings of 19.04. The third, a beforeafter with propensity matched comparison group found a PMPM drug cost savings of $21.36. Flags (alerts) were reduced for two types of alert categories across all evaluations and their sub-group evaluations. The first, alerts for drugs on the Prescription Advantage List (PAL) iv were substantially reduced with a percentage reduction of 19.2% for all persons having a pharmacist review. The PAL list a voluntary preferred drug list sponsored by North Carolina Medicaid. The second, alerts for drugs on the Clinical Initiatives List were also substantially reduced with a percentage reduction of 9.6% for all residents having a pharmacist review. The Clinical Initiatives List was a list of drugs submitted by consultant pharmacy organizations that were targeted for cost-effectiveness and quality concerns. Overall, Phases 1, 2 and 3 of the Initiative produced consultant pharmacist reviews for 19,144 nursing home residents. These reviews generated 17,545 recommendations that resulted in greater than 10,000 drug changes. Findings from this dissertation support the conclusion that a targeted program using pharmacists to review patient profiles may be quickly launched and expeditiously conducted across large numbers of patients, at least in long-term-care settings

    Adviser\u27s Guide to Health Care, Volume 2: Consulting Services

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    https://egrove.olemiss.edu/aicpa_guides/2721/thumbnail.jp

    Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

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    http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.asp
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