The Informatics Opportunities at the Intersection of Patient Safety and Clinical Informatics

Journal of the American Medical Informatics Association

Volumn 15, Issue 4, 2008, Pages 397-407

  Kilbridge, Peter M ^a,b   Classen, David C ^b,c  

^a WASHINGTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b ST LOUIS CHILDREN S HOSPITAL   (United States)

^c UNIVERSITY OF UTAH SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AMBULATORY CARE; ARTICLE; AUTOMATION; COMPUTER SYSTEM; DECISION SUPPORT SYSTEM; DRUG INFORMATION; HEALTH CARE ORGANIZATION; HEALTH CARE QUALITY; HOSPITAL PATIENT; HOSPITAL PHARMACY; HUMAN; MEDICAL DOCUMENTATION; MEDICAL INFORMATICS; MEDICAL INFORMATION SYSTEM; MODEL; PATIENT CARE; PATIENT MONITORING; PATIENT SAFETY; PHARMACIST; QUALITY CONTROL; STANDARD;

DECISION SUPPORT SYSTEMS, CLINICAL; DELIVERY OF HEALTH CARE; HUMANS; IATROGENIC DISEASE; MEDICAL ERRORS; MEDICAL INFORMATICS; MEDICAL RECORDS SYSTEMS, COMPUTERIZED; SAFETY MANAGEMENT; SYSTEMS INTEGRATION;

EID: 45849091138     PISSN: 10675027     EISSN: None     Source Type: Journal    
DOI: 10.1197/jamia.M2735     Document Type: Article

References (91)

1. Kohn L.T., Corrigan J.M., and Donaldson M.S. To Err is Human: Building a Safer Health System (2000), National City Press, Washington, DC
2. Jick H. Drugs-remarkably nontoxic. N Engl J Med 291 (1974) 824-828
3. Bates D.W., Leape L.L., Cullen D.J., et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 280 (1998) 1311-1316
4. Bates D.W., and Gawande A.A. Improving safety with information technology. N Engl J Med 348 (2003) 2526-2534
5. Bates D.W. Using information technology to reduce rates of medication errors in hospitals. BMJ 320 (2000) 788-791
6. McDonald C.J., Tierney W.M., Overhage J.M., Dexter P.R., Takesue B.Y., and Abernathy G. The Three Legged Stool (1997), Regenstrief Institute for Health Care, Indianapolis, IN
7. Evans R.S., Pestotnik S.L., Classen D.C., et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 338 (1998) 232-238
8. Aspden P., Corrigan J.M., Wolcott J., and Erickson S.M. Patient Safety: Achieving a New Standard for Care (2004), National Academies Press, Washington, DC
9. Bates D.W. Using information technology to improve surgical safety. Br J Surg 91 (2004) 939-940
10. McDonald C.J. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 295 (1976) 1351-1355
11. Keeping patients safe: Institute of Medicine looks at transforming nurses' work environment. Qual Lett Healthc Lead 16 (2004) 9-11
12. Crossing the Quality Chasm: A New Health System for the 21st Century (2002), National Academies Press, Washington, DC
13. Hurtado M., Swift E., and Corrigan J.M. Envisioning the National Health Care Quality Report (2001), National Academies Press, Washington, DC
14. In: Aspden P., and Corrigan J.M. (Eds). Patient Safety: Achieving a New Standard of Care (2004), National Academies Press, Washington, DC
15. Bagian J.P. Patient safety: What is really at issue?. Front Health Serv Manage 22 (2005) 3-16
16. Petersen L.A., Orav E.J., Teich J.M., O'Neil A.C., and Brennan T.A. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 24 (1998) 77-87
17. Sidlow R., and Katz-Sidlow R.J. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf 32 (2006) 32-36
18. Aiken L.H., Clarke S.P., Silber J.H., and Sloane D. Hospital nurse staffing, education, and patient mortality. LDI Issue Brief 9 2 (2003) 1-4
19. Aiken L.H., Clarke S.P., Cheung R.B., Sloane D.M., and Silber J.H. Educational levels of hospital nurses and surgical patient mortality. JAMA 290 (2003) 1617-1623
20. Krohn R. How healthcare IT can address the nursing shortage. J Healthc Inf Manag 20 2 (2006) 21-23
21. Rall M., Manser T., Guggenberger H., Gaba D.M., and Unertl K. [Patient safety and errors in medicine: development, prevention and analyses of incidents]. Anasthesiol Intensivmed Notfallmed Schmerzther 36 (2001) 321-330
22. Scalese R.J., Obeso V.T., and Issenberg S.B. Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med 23 Suppl 1 (2008) 46-49
23. Brydges R., Kurahashi A., Brummer V., Satterthwaite L., Classen R., and Dubrowski A. Developing criteria for proficiency-based training of surgical technical skills using simulation: Changes in performances as a function of training year. J Am Coll Surg 206 (2008) 205-211
24. Dillon G.F., Boulet J.R., Hawkins R.E., and Swanson D.B. Simulations in the United States Medical Licensing Examination (USMLE). Qual Saf Health Care 13 Suppl 1 (2004) i41-i45
25. Williams T.L., Lemkau Jr. H.L., and Burrows S. The economics of academic health sciences libraries: cost recovery in the era of big science. Bull Med Libr Assoc 76 (1988) 317-322
26. Buckeridge D.L., and Goel V. Medical informatics in an undergraduate curriculum: a qualitative study. BMC Med Inform Decis Mak 2 (2002) 6
27. Clarke J.L., Meiris D.C., and Nash D.B. Electronic personal health records come of age. Am J Med Qual 21 3 Suppl (2006) 5S-15S
28. Tang P.C., Ash J.S., Bates D.W., Overhage J.M., and Sands D.Z. Personal health records: Definitions, benefits, and strategies for overcoming barriers to adoption. J Am Med Inform Assoc 13 (2006) 121-126
29. Ash J.S., and Bates D.W. Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. J Am Med Inform Assoc 12 (2005) 8-12
30. Middleton B., Hammond W.E., Brennan P.F., and Cooper G.F. Accelerating U.S. EHR adoption: How to get there from here. recommendations based on the 2004 ACMI retreat. J Am Med Inform Assoc 12 (2005) 13-19
31. Berner E.S., Detmer D.E., and Simborg D. Will the wave finally break?. A brief view of the adoption of electronic medical records in the United States. J Am Med Inform Assoc 12 (2005) 3-7
32. Classen D., Avery J., and Bates D.W. Evaluation and Certification of Computerized Provider Order Entry Systems. J Am Med Inform Assoc 14 (2007) 48-55
33. Middleton B. Achieving U.S. Health information technology adoption: the need for a third hand. Health Aff (Millwood) 24 (2005) 1269-1272
34. Halamka J., Aranow M., Ascenzo C., et al. Health care IT collaboration in Massachusetts: The experience of creating regional connectivity. J Am Med Inform Assoc 12 (2005) 596-601
35. Halamka J., Aranow M., Ascenzo C., et al. E-Prescribing collaboration in Massachusetts: Early experiences from regional prescribing projects. J Am Med Inform Assoc 13 (2006) 239-244
36. Classen D.C., Kanhouwa M., Will D., Casper J., Lewin J., and Walker J. The patient safety institute demonstration project: a model for implementing a local health information infrastructure. J Healthc Inf Manag 19 (2005) 75-86
37. Frisse M.E. State and community-based efforts to foster interoperability. Health Aff (Millwood) 24 (2005) 1190-1196
38. Garg A.X., Adhikari N.K., McDonald H., et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 293 (2005) 1223-1238
39. Kuperman G.J., and Gibson R.F. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 139 (2003) 31-39
40. Cross R.K., and Finkelstein J. Feasibility and acceptance of a home telemanagement system in patients with inflammatory bowel disease: a 6-month pilot study. Dig Dis Sci 52 (2007) 357-364
41. Fritzsche D., Eitz T., Laczkovics A., et al. Early detection of mechanical valve dysfunction using a new home monitoring device. Ann Thorac Surg 83 (2007) 542-548
42. O'Connor C.M., Velazquez E.J., Gardner L.H., et al. Comparison of coronary artery bypass grafting versus medical therapy on long-term outcome in patients with ischemic cardiomyopathy (a 25-year experience from the Duke Cardiovascular Disease Databank). Am J Cardiol 90 (2002) 101-107
43. Bruce B., and Fries J.F. The Arthritis, Rheumatism and Aging Medical Information System (ARAMIS): Still young at 30 years. Clin Exp Rheumatol 23 Suppl 39 (2005) S163-S167
44. Charting a Course for the 21st Century: NLM's Long Range Plan 2006-2016 (2006), U.S. Department of Health and Human Services, National Institutes of Health, Washington, DC
45. Haug C., Gotzsche P.C., and Schroeder T.V. Registries and registration of clinical trials. N Engl J Med 353 (2005) 2811-2812
46. Zarin D.A., and Keselman A. Registering a clinical trial in ClinicalTrials.gov. Chest 131 (2007) 909-912
47. Steinbrook R. Public registration of clinical trials. N Engl J Med 351 (2004) 315-317
48. Leape L.L., Brennan T.A., Laird N., et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324 (1991) 377-384
49. Dexter P.R., Perkins S., Overhage J.M., Maharry K., Kohler R.B., and McDonald C.J. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med 345 (2001) 965-970
50. Dexter P.R., Perkins S.M., Maharry K.S., Jones K., and McDonald C.J. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 292 (2004) 2366-2371
51. Tierney W.M., Overhage J.M., Takesue B.Y., et al. Computerizing guidelines to improve care and patient outcomes: The example of heart failure. J Am Med Inform Assoc 2 (1995) 316-322
52. Tierney W.M., Overhage J.M., Murray M.D., et al. Effects of computerized guidelines for managing heart disease in primary care. J Gen Intern Med 18 (2003) 967-976
53. Ozdas A., Speroff T., Waitman L.R., Ozbolt J., Butler J., and Miller R.A. Integrating "best of care" protocols into clinicians' workflow via care provider order entry: Impact on quality-of-care indicators for acute myocardial infarction. J Am Med Inform Assoc 13 (2006) 188-196
54. Celi L.A., Hassan E., Marquardt C., Breslow M., and Rosenfeld B. The eICU: It's not just telemedicine. Crit Care Med 29 Suppl (2001) N183-N189
55. Clemmer T.P. Computers in the ICU: Where we started and where we are now. J Crit Care 19 (2004) 201-207
56. Kawamoto K., Houlihan C.A., Balas E.A., and Lobach D.F. Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. BMJ 330 7494 (2005) 765
57. Pryor T.A., Gardner R.M., Clayton P.D., and Warner H.R. The HELP system. J Med Syst 7 (1983) 87-102
58. Barnett O. Computers in medicine. JAMA 263 (1990) 2631-2633
59. Safran C., Porter D., Lightfoot J., et al. ClinQuery: A system for online searching of data in a teaching hospital. Ann Intern Med 111 (1989) 751-756
60. Cullen D.J., Bates D.W., Small S.D., Cooper J.B., Nemeskal A.R., and Leape L.L. The incident reporting system does not detect adverse drug events: A problem for quality improvement. Jt Comm J Qual Improv 21 (1995) 541-548
61. Mekhjian H.S., Bentley T.D., Ahmad A., and Marsh G. Development of a Web-based event reporting system in an academic environment. J Am Med Inform Assoc 11 (2004) 11-18
62. Oken A., Rasmussen M.D., Slagle J.M., et al. A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. Anesthesiology 107 (2007) 909-922
63. Nuckols T.K., Bell D.S., Liu H., Paddock S.M., and Hilborne L.H. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care 16 (2007) 164-168
64. Harris C.B., Krauss M.J., Coopersmith C.M., et al. Patient safety event reporting in critical care: A study of three intensive care units. Crit Care Med 35 (2007) 1068-1076
65. Classen D.C., Pestotnik S.L., Evans R.S., and Burke J.P. Computerized surveillance of adverse drug events in hospital patients. JAMA 266 (1991) 2847-2851
66. Jha A.K., Kuperman G.J., Teich J.M., et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 5 (1998) 305-314
67. Kilbridge P.M., Campbell U.C., Cozart H.B., and Mojarrad M.G. Automated surveillance for adverse drug events at a community hospital and an academic medical center. J Am Med Inform Assoc 13 (2006) 372-377
68. Kilbridge P.M., and Classen D.C. Automated surveillance for adverse events in hospitalized patients: back to the future. Qual Saf Health Care 15 (2006) 148-149
69. Kilbridge P. Implementation of a system for computerized adverse drug event surveillance and intervention at an academic medical center. J Clin Outcomes 13 (2006) 94-100
70. Honigman B., Light P., Pulling R.M., and Bates D.W. A computerized method for identifying incidents associated with adverse drug events in outpatients. Int J Med Inform 61 (2001) 21-32
71. Gurwitz J.H., Field T.S., Harrold L.R., et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289 (2003) 1107-1116
72. Melton G.B., and Hripcsak G. Automated detection of adverse events using natural language processing of discharge summaries. J Am Med Inform Assoc 12 (2005) 448-457
73. Hammond W.E. The role of standards in electronic prescribing. Health Aff (Millwood) (2004) Suppl Web Exclusives:W4-325-7.
74. The Commission on Systemic Interoperability. http://endingthedocumentgame.gov Accessed June 2008.
75. Brooks R.G., Menachemi N., Burke D., and Clawson A. Patient safety-related information technology utilization in urban and rural hospitals. J Med Syst 29 (2005) 103-109
76. Menachemi N., Burke D., Clawson A., and Brooks R.G. Information technologies in Florida's rural hospitals: Does system affiliation matter?. J Rural Health 21 (2005) 263-268
77. Ohsfeldt R.L., Ward M.M., Schneider J.E., et al. Implementation of hospital computerized physician order entry systems in a rural state: Feasibility and financial impact. J Am Med Inform Assoc 12 (2005) 20-27
78. Yasnoff W.A., Humphreys B.L., Overhage J.M., et al. A consensus action agenda for achieving the national health information infrastructure. J Am Med Inform Assoc 11 (2004) 332-338
79. Walker J., Pan E., Johnston D., Adler-Milstein J., Bates D.W., and Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood) (2005) Suppl Web Exclusives:W5-10-W5-8.
80. Walker J.M. Electronic medical records and health care transformation. Health Aff (Millwood) 24 (2005) 1118-1120
81. Teich J.M., Osheroff J.A., Pifer E.A., Sittig D.F., and Jenders R.A. Clinical decision support in electronic prescribing: recommendations and an action plan: Report of the joint clinical decision support workgroup. J Am Med Inform Assoc 12 (2005) 365-376
82. Shah N.R., Seger A.C., Seger D.L., et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 13 (2006) 5-11
83. Miller R.A., Gardner R.M., Johnson K.B., and Hripcsak G. Clinical decision support and electronic prescribing systems: A time for responsible thought and action. J Am Med Inform Assoc 12 (2005) 403-409
84. Osheroff J.A., Teich J.M., Middleton B., Steen E.B., Wright A., and Detmer D.E. A roadmap for national action on clinical decision support. J Am Med Inform Assoc 14 (2007) 141-145
85. Koppel R., Metlay J.P., Cohen A., et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 293 (2005) 1197-1203
86. Han Y.Y., Carcillo J.A., Venkataraman S.T., et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116 (2005) 1506-1512
87. Kilbridge P.M., Welebob E.M., and Classen D.C. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Qual Saf Health Care 15 (2006) 81-84
88. Miller R.A., and Gardner R.M. Summary recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, The Computer-based Patient Record Institute, The Medical Library Association, The Association of Academic Health Science Libraries, The American Health Information Management Association, and The American Nurses Association. Ann Intern Med 127 (1997) 842-845
89. Miller R.A., and Gardner R.M. Recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, Computer-based Patient Record Institute, Medical Library Association, Association of Academic Health Science Libraries, American Health Information Management Association, American Nurses Association. J Am Med Inform Assoc 4 (1997) 442-457
90. Performance measurement: accelerating improvement. Institute of Medicine (2006), National Academy Press, Washington, DC
91. 2004 ASHP Leadership Conference on Pharmacy Practice Management Executive Summary: improving patient care and medication safety. Am J Health Syst Pharm 62 (2005) 1303-1310