scholarly journals Using patient safety-event report data to assess health-IT safety: benefits and challenges

2019 ◽  
Vol 1 (3) ◽  
pp. e104-e105
Author(s):  
Jessica L Howe ◽  
A Zachary Hettinger ◽  
Raj M Ratwani
Keyword(s):  
Patient Safety ◽  
Health It ◽  
Event Report ◽  
Safety Event ◽  
Report Data

scholarly journals Where are health IT patient safety event reports hiding? Identifying health IT patient safety events in self-reported databases

2019 ◽  
Vol 63 (1) ◽  
pp. 703-707
Author(s):  
Katharine T. Adams ◽  
Jessica L. Howe ◽  
Michael J. Gaunt ◽  
Raj M. Ratwani ◽  
Allan Fong
Keyword(s):  
Patient Safety ◽  
Descriptive Analysis ◽  
The Self ◽  
Manual Annotation ◽  
Health It ◽  
Event Type ◽  
Annotation Process ◽  
Specific Event ◽  
Safety Event ◽  
Additional Support

Introduction: The objective of this paper is to describe a manual annotation process to identify likely health information technology (IT) related patient safety event (PSE) reports and the descriptive analysis of the self-reported event type categories of the resulting likely health IT related events. Methods: 5287 PSE reports were manually coded as likely or unlikely related to health IT and the structured general and specific event type categories were analyzed. Results: Of the 2435 likely health IT related events, 1200 were categorized as medication error events, 709 described an error related to a procedure, treatment, or test, and the remaining events were distributed among 19 different general event types. Discussion: The variety of self-reported general and specific event categories indicates a potential need to provide additional support for individuals reporting events to capture contextual nuances and incorporating advanced techniques to assist researchers and safety officers in identifying health IT related events.

scholarly journals Identifying health information technology related safety event reports from patient safety event report databases

2018 ◽  
Vol 86 ◽  
pp. 135-142 ◽  
Author(s):  
Allan Fong ◽  
Katharine T. Adams ◽  
Michael J. Gaunt ◽  
Jessica L. Howe ◽  
Kathryn M. Kellogg ◽  
...  
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Event Report ◽  
Safety Event

scholarly journals Implications of electronic health record downtime: an analysis of patient safety event reports

2017 ◽  
Vol 25 (2) ◽  
pp. 187-191 ◽  
Author(s):  
Ethan Larsen ◽  
Allan Fong ◽  
Christian Wernz ◽  
Raj M Ratwani
Keyword(s):  
Patient Safety ◽  
Electronic Health Record ◽  
Clinical Information ◽  
Health Record ◽  
Patient Identification ◽  
Safety Hazards ◽  
Patient Handoff ◽  
Safety Event ◽  
Report Data ◽  
Electronic Health

Abstract Objective We sought to understand the types of clinical processes, such as image and medication ordering, that are disrupted during electronic health record (EHR) downtime periods by analyzing the narratives of patient safety event report data. Materials and Methods From a database of 80 381 event reports, 76 reports were identified as explicitly describing a safety event associated with an EHR downtime period. These reports were analyzed and categorized based on a developed code book to identify the clinical processes that were impacted by downtime. We also examined whether downtime procedures were in place and followed. Results The reports were coded into categories related to their reported clinical process: Laboratory, Medication, Imaging, Registration, Patient Handoff, Documentation, History Viewing, Delay of Procedure, and General. A majority of reports (48.7%, n = 37) were associated with lab orders and results, followed by medication ordering and administration (14.5%, n = 11). Incidents commonly involved patient identification and communication of clinical information. A majority of reports (46%, n = 35) indicated that downtime procedures either were not followed or were not in place. Only 27.6% of incidents (n = 21) indicated that downtime procedures were successfully executed. Discussion Patient safety report data offer a lens into EHR downtime–related safety hazards. Important areas of risk during EHR downtime periods were patient identification and communication of clinical information; these should be a focus of downtime procedure planning to reduce safety hazards. Conclusion EHR downtime events pose patient safety hazards, and we highlight critical areas for downtime procedure improvement.

An Evaluation of Patient Safety Event Report Categories Using Unsupervised Topic Modeling

2015 ◽  
Vol 54 (04) ◽  
pp. 338-345 ◽  
Author(s):  
A. Fong ◽  
R. Ratwani
Keyword(s):  
Patient Safety ◽  
Natural Language Processing ◽  
Natural Language ◽  
Language Processing ◽  
Topic Modeling ◽  
Free Text ◽  
Event Data ◽  
Event Type ◽  
Modeling Approach ◽  
Safety Event

SummaryObjective: Patient safety event data repositories have the potential to dramatically improve safety if analyzed and leveraged appropriately. These safety event reports often consist of both structured data, such as general event type categories, and unstructured data, such as free text descriptions of the event. Analyzing these data, particularly the rich free text narratives, can be challenging, especially with tens of thousands of reports. To overcome the resource intensive manual review process of the free text descriptions, we demonstrate the effectiveness of using an unsupervised natural language processing approach.Methods: An unsupervised natural language processing technique, called topic modeling, was applied to a large repository of patient safety event data to identify topics, or themes, from the free text descriptions of the data. Entropy measures were used to evaluate and compare these topics to the general event type categories that were originally assigned by the event reporter.Results: Measures of entropy demonstrated that some topics generated from the un-supervised modeling approach aligned with the clinical general event type categories that were originally selected by the individual entering the report. Importantly, several new latent topics emerged that were not originally identified. The new topics provide additional insights into the patient safety event data that would not otherwise easily be detected.Conclusion: The topic modeling approach provides a method to identify topics or themes that may not be immediately apparent and has the potential to allow for automatic reclassification of events that are ambiguously classified by the event reporter.

scholarly journals Perilaku Kepatuhan Perawat Melaksanakan SOP Terhadap Kejadian Keselamatan Pasien di Rumah Sakit X Kendari

2017 ◽  
Vol 12 (1) ◽  
pp. 138
Author(s):  
Iriyanto Pagala ◽  
Zahroh Shaluhiyah ◽  
Baju Widjasena
Keyword(s):  
Patient Safety ◽  
Peer Support ◽  
Dominant Factor ◽  
Hospital Inpatient ◽  
Care Hospital ◽  
Patient Death ◽  
Cross Sectional ◽  
Patient Falls ◽  
Safety Event ◽  
Perception Of Support

ABSTRAKKeselamatan pasien adalah pasien bebas dari cedera yang tidak seharusnya terjadi atau bebas dari cedera yang potensial akan terjadi (penyakit,cedera fisik/sosial psikologis, cacat, kematian) terkait dengan pelayanan kesehatan. Di Rumah Sakit X Kendari  data kejadian keselamatan pasien pada tahun 2012 terdiri dari  kesalahan dalam pemeriksaan laborat,  pasien jatuh, salah pemberian seri kolf darah, pasien terbentur, salah dalam pemberian obat, kasus kematian pasien. Berdasarkan penentuan perioritas masalah yang akan di teliti yaitu pasien jatuh dari tempat tidur. Salah satu penyebabnya yaitu kurang patuhnya perawat dalam melaksanakan SOP resiko pasien jatuh. Tujuan penelitian ini adalah menganalisa faktor yang berhubungan antara karakteristik, pengetahuan, sikap, presepsi dukungan supervisior, presepsi dukungan sesama perawat, kenyamanan tempat/unit kerja dengan prilaku kepatuhan perawat dalam melaksanakan SOP resiko pasien jatuh terhadap terjadinya kejadian keselamatan pasien di Unit Rawat Inap Rumah Sakit X Kendari. Jenis penelitian yang digunakan adalah penelitian Explanatory Research dengan rancangan Cross sectional. Sampel dalam penelitian ini berjumlah 134 perawat ruang rawat inap. Hasil penelitian menunjukan terdapat 4 variabel yang berhubungan yaitu pengetahuan (p= 0,005), sikap (p = 0,035), persepsi dukungan supervisior (p= 0,000), persepsi dukungan sesama perawat (p= 0,003) dan faktor yang paling dominan berhubungan adalah persepsi dukungan supervisior (OR = 5,504).Kata Kunci : Perawat, Kepatuhan Melaksanakan SOP Compliance Behavior of Nurses Against Genesis SOP Implementing Patient Safety in Hospital X Kendari : The safety of patients were free of injury that is not supposed to happen or free from potential injury will occur (disease, physical injury / social psychological, disability, death) associated with health care. Hospital X Kendari patient safety event data in 2012 consisted of errors in laboratory examination, patient falls, one giving blood kolf series, patient knock, one in drug delivery, patient death cases. Based on the determination of the issues to be priorities in carefully which patients falling out of bed. One reason is lack of nurses in implementing SOP obedient, patient risk falling. The purpose of this study was to analyze factors related to the characteristics, knowledge, attitudes, perception supervisior support, perception of peer support nurse, comfort / unit with the behavior of nurses in implementing SOP compliance risk of the patient fell against the occurrence of patient safety in the Hospital Inpatient Unit X Kendari. This type of research is Explanatory Research research with cross sectional design. The sample in this study amounted to 134 inpatient room nurse. The results showed there were four variables related to that knowledge (p = 0.005), attitude (p = 0.035), perception of support supervisior (p = 0.000), perception of peer support nurses (p = 0.003) and the most dominant factor is the perception of support supervisior (OR = 5.504).Keywords: Nurses, SOP Implement Compliance

Responding to health information technology reported safety events: Insights from patient safety event reports

2019 ◽  
Vol 24 (3) ◽  
pp. 118-124 ◽  
Author(s):  
Katharine T Adams ◽  
Tracy C Kim ◽  
Allan Fong ◽  
Jessica L Howe ◽  
Kathryn M Kellogg ◽  
...  
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Healthcare Systems ◽  
Healthcare Staff ◽  
Or Education ◽  
Training And Education ◽  
Safety Event ◽  
Policy Information

Objective We analyzed the described resolutions of patient safety event reports related to health information technology to determine how healthcare systems responded to these events, recognizing that certain types of solutions such as training and education have a limited impact. Methods A large database of over 1.7 million patient safety event reports was filtered to include those identified by the reporter as being related to health information technology. The resolution text was manually reviewed and coded into one or more of four categories: No Resolution, Training/Education, Policy, Information Technology-oriented solution. Results Most events (64%) did not include a resolution. Of those that did, Training/Education was the most commonly reported single or component of a multi-pronged solution (55%), followed by Information Technology (45%). Only 59 events (6% of resolutions) described more than one method of resolution. Conclusion Health information technology-related patient safety event resolutions most often described a solution that suggested additional training or education for healthcare staff, despite the recognized limitations of training and education in resolving these events. Few events suggested multiple resolution methods. Ensuring health information technology-related events are resolved and incorporate effective solutions should be a continued focus area for healthcare systems.

scholarly journals Patient safety on weekends and weekdays: A comparative study of two hospitals in California

2013 ◽  
Vol 2 (3) ◽  
pp. 66
Author(s):  
Alberta T Pedroja ◽  
Mary A Blegen ◽  
Rebecca Abravanel ◽  
Arnold J Stromberg ◽  
Bruce Spurlock
Keyword(s):  
Patient Safety ◽  
Comparative Study ◽  
Incident Report ◽  
Patient Harm ◽  
Staffing Levels ◽  
Research Findings ◽  
Report Data ◽  
And Shifts

Background: Most clinicians believe that hospitals are less safe on the weekends, but the research findings have been mixed. In addition, the investigations have largely examined the outcomes of patients admitted on weekends versus weekdays and not patient harm that occurred on weekends against patient harm that occurred during the week. Objective: To compare the extent of patient harm that occurred on weekend days with the harm that occurred on weekdays. Methods: Using daily incident report data for an entire year from two hospitals in California we measured the number of incidents each day, the average harm per incident, and the total daily harm from all incidents. Analyses were done separately for the two different hospitals and controlled for daily patient census. Harm per incident was assessed to determine whether reporting patterns on weekdays differed from weekends. Results: There were fewer incidents per day and less total daily harm on weekend days than days during the workweek in both hospitals (p < .05). Patient to nurse ratios are held at the same level across all days and shifts. There did not appear to be a systematic tendency to under-report incidents on the weekends. Conclusion: The data strongly suggest that there is less harm to patients due to healthcare error on the weekends than during the week. Further work is needed to determine whether these findings would apply in hospitals with varying staffing levels.

scholarly journals An Analysis of Patient Safety Incident Reports Associated with Electronic Health Record Interoperability

2017 ◽  
Vol 08 (02) ◽  
pp. 593-602 ◽  
Author(s):  
Katharine Adams ◽  
Jessica Howe ◽  
Allan Fong ◽  
Joseph Puthumana ◽  
Kathryn Kellogg ◽  
...  
Keyword(s):  
Patient Safety ◽  
Electronic Health Record ◽  
Health Record ◽  
Health It ◽  
Specific Patient ◽  
It Systems ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Electronic Health

SummaryBackground: With the widespread use of electronic health records (EHRs) for many clinical tasks, interoperability with other health information technology (health IT) is critical for the effective delivery of care. While it is generally recognized that poor interoperability negatively impacts patient care, little is known about the specific patient safety implications. Understanding the patient safety implications will help prioritize interoperability efforts around architectures and standards.Objectives: Our objectives were to (1) identify patient safety incident reports that reflect EHR interoperability challenges with other health IT, and (2) perform a detailed analysis of these reports to understand the health IT systems involved, the clinical care processes impacted, whether the incident occurred within or between provider organizations, and the reported severity of the patient safety events.Methods: From a database of 1.735 million patient safety event (PSE) reports spanning multiple provider organizations, 2625 reports that were indicated as being health IT related by the event reporter were reviewed to identify EHR interoperability related reports. Through a rigorous coding process 209 EHR interoperability related events were identified and coded.Results: The majority of EHR interoperability PSE reports involved interfacing with pharmacy systems (i.e. medication related), followed by laboratory, and radiology. Most of the interoperability challenges in these clinical areas were associated with the EHR receiving information from other health IT systems as opposed to the EHR sending information to other systems. The majority of EHR interoperability challenges were within a provider organization and while many of the safety events reached the patient, only a few resulted in patient harm.Conclusions: Interoperability efforts should prioritize systems in pharmacy, laboratory, and radiology. Providers should recognize the need to improve EHRs interfacing with other health IT systems within their own organization.Citation: Adams KT, Howe JL, Fong A, Puthumana JS, Kellogg KM, Gaunt M, Ratwani RM. An analysis of patient safety incident reports associated with electronic health record interoperability. Appl Clin Inform 2017; 8: 593–602 https://doi.org/10.4338/ACI-2017-01-RA-0014

scholarly journals Effects of health information technology on patient outcomes: a systematic review

2015 ◽  
Vol 23 (5) ◽  
pp. 1016-1036 ◽  
Author(s):  
Samantha K Brenner ◽  
Rainu Kaushal ◽  
Zachary Grinspan ◽  
Christine Joyce ◽  
Inho Kim ◽  
...  
Keyword(s):  
Information Technology ◽  
Patient Safety ◽  
Health Information Technology ◽  
Health Information ◽  
Clinical Decision ◽  
Cochrane Library ◽  
Health It ◽  
Term Care ◽  
Safety Outcomes

Abstract Objective To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes. Materials and Methods The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes. Results Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry. Discussion and Conclusion Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

Sign in / Sign up

Export Citation Format

Share Document