1
|
Rzewnicki D, Kanvinde A, Gillespie S, Orenstein E. Association of patient photographs and reduced retract-and-reorder events. JAMIA Open 2024; 7:ooae042. [PMID: 38957593 PMCID: PMC11218880 DOI: 10.1093/jamiaopen/ooae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 02/13/2024] [Accepted: 05/03/2024] [Indexed: 07/04/2024] Open
Abstract
Background Wrong-patient order entry (WPOE) is a potentially dangerous medical error. It remains unknown if patient photographs reduce WPOE in the pediatric inpatient population. Materials and Methods Order sessions from a single pediatric hospital system were examined for retract-and-reorder (RAR) events, a surrogate WPOE measure. We determined the association of patient photographs with the proportion of order sessions resulting in a RAR event, adjusted for patient, provider, and ordering context. Results In multivariable analysis, the presence of a patient photo in the electronic health record was associated with 40% lower odds of a RAR event (aOR: 0.60, 95% CI: 0.48-0.75), while cardiac and ICU contexts had higher RAR frequency (aOR: 2.12, 95% CI: 1.69-2.67 and 2.05, 95% CI: 1.71-2.45, respectively). Discussion and Conclusion Patient photos were associated with lower odds of RAR events in the pediatric inpatient setting, while high acuity locations may be at higher risk. Patient photographs may reduce WPOE without interruptions.
Collapse
Affiliation(s)
- Daniel Rzewnicki
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Atul Kanvinde
- Information Technology, Shepherd Center, Atlanta, GA 30305, United States
| | - Scott Gillespie
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, United States
- Information Services and Technology, Children’s Healthcare of Atlanta, Atlanta, GA 30329, United States
| |
Collapse
|
2
|
Schroers G, Pfieffer J, Andersen B, O'Rourke J. An Interruption Management Education Bundle: Feasibility Testing With Nursing Students. Nurse Educ 2024; 49:189-194. [PMID: 38086173 DOI: 10.1097/nne.0000000000001583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
BACKGROUND Interruptions and distractions are pervasive in health care settings, increase risks for errors, and decrease task efficiency. Researchers recommend the use of strategies to mitigate their negative effects. PURPOSE The purpose was to assess the feasibility and acceptability of (1) an education bundle that included an interruption management strategy and (2) simulated scenarios with embedded interruptions and distractions. METHODS Nineteen undergraduate nursing students participated in this repeated-measures, multimethods feasibility study. Data on interruption management behaviors were collected across 3 timepoints via direct observation of individual-simulated medication administration. Participants' perceptions of the education bundle were explored via semistructured interviews. RESULTS Participants described the simulated scenarios as realistic and interruption management strategy as easy to use and remember. Participants voiced increased confidence in handling interruptions after learning the strategy. The strategy averaged 4 seconds to apply. CONCLUSIONS Findings support the feasibility and acceptability of the bundle and need for studies to investigate the impact of the strategy on errors and task durations.
Collapse
Affiliation(s)
- Ginger Schroers
- Author Affiliations: Assistant Professor (Dr Schroers), Instructor (Ms Pfieffer), and Instructor (Ms Andersen), Marcella Niehoff School of Nursing, Loyola University Chicago, Maywood, Illinois; and Associate Dean of Academic Affairs and Associate Professor (Dr O'Rourke), Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois
| | | | | | | |
Collapse
|
3
|
Baratta LR, Harford D, Sinsky CA, Kannampallil T, Lou SS. Characterizing the Patterns of Electronic Health Record-Integrated Secure Messaging Use: Cross-Sectional Study. J Med Internet Res 2023; 25:e48583. [PMID: 37801359 PMCID: PMC10589827 DOI: 10.2196/48583] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Communication among health care professionals is essential for the delivery of safe clinical care. Secure messaging has rapidly emerged as a new mode of asynchronous communication. Despite its popularity, relatively little is known about how secure messaging is used and how such use contributes to communication burden. OBJECTIVE This study aims to characterize the use of an electronic health record-integrated secure messaging platform across 14 hospitals and 263 outpatient clinics within a large health care system. METHODS We collected metadata on the use of the Epic Systems Secure Chat platform for 6 months (July 2022 to January 2023). Information was retrieved on message volume, response times, message characteristics, messages sent and received by users, user roles, and work settings (inpatient vs outpatient). RESULTS A total of 32,881 users sent 9,639,149 messages during the study. Median daily message volume was 53,951 during the first 2 weeks of the study and 69,526 during the last 2 weeks, resulting in an overall increase of 29% (P=.03). Nurses were the most frequent users of secure messaging (3,884,270/9,639,149, 40% messages), followed by physicians (2,387,634/9,639,149, 25% messages), and medical assistants (1,135,577/9,639,149, 12% messages). Daily message frequency varied across users; inpatient advanced practice providers and social workers interacted with the highest number of messages per day (median 19). Conversations were predominantly between 2 users (1,258,036/1,547,879, 81% conversations), with a median of 2 conversational turns and a median response time of 2.4 minutes. The largest proportion of inpatient messages was from nurses to physicians (972,243/4,749,186, 20% messages) and physicians to nurses (606,576/4,749,186, 13% messages), while the largest proportion of outpatient messages was from physicians to nurses (344,048/2,192,488, 16% messages) and medical assistants to other medical assistants (236,694/2,192,488, 11% messages). CONCLUSIONS Secure messaging was widely used by a diverse range of health care professionals, with ongoing growth throughout the study and many users interacting with more than 20 messages per day. The short message response times and high messaging volume observed highlight the interruptive nature of secure messaging, raising questions about its potentially harmful effects on clinician workflow, cognition, and errors.
Collapse
Affiliation(s)
- Laura R Baratta
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, Saint Louis, MO, United States
| | - Derek Harford
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
| | | | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
| | - Sunny S Lou
- Department of Anesthesiology, Washington University School of Medicine, Saint Louis, MO, United States
| |
Collapse
|
4
|
Rabbani N, Ho M, Dash D, Calway T, Morse K, Chadwick W. Pseudorandomized Testing of a Discharge Medication Alert to Reduce Free-Text Prescribing. Appl Clin Inform 2023; 14:470-477. [PMID: 37015344 PMCID: PMC10266904 DOI: 10.1055/a-2068-6940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/03/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Pseudorandomized testing can be applied to perform rigorous yet practical evaluations of clinical decision support tools. We apply this methodology to an interruptive alert aimed at reducing free-text prescriptions. Using free-text instead of structured computerized provider order entry elements can cause medication errors and inequity in care by bypassing medication-based clinical decision support tools and hindering automated translation of prescription instructions. OBJECTIVE The objective of this study is to evaluate the effectiveness of an interruptive alert at reducing free-text prescriptions via pseudorandomized testing using native electronic health records (EHR) functionality. METHODS Two versions of an EHR alert triggered when a provider attempted to sign a discharge free-text prescription. The visible version displayed an interruptive alert to the user, and a silent version triggered in the background, serving as a control. Providers were assigned to the visible and silent arms based on even/odd EHR provider IDs. The proportion of encounters with a free-text prescription was calculated across the groups. Alert trigger rates were compared in process control charts. Free-text prescriptions were analyzed to identify prescribing patterns. RESULTS Over the 28-week study period, 143 providers triggered 695 alerts (345 visible and 350 silent). The proportions of encounters with free-text prescriptions were 83% (266/320) and 90% (273/303) in the intervention and control groups, respectively (p = 0.01). For the active alert, median time to action was 31 seconds. Alert trigger rates between groups were similar over time. Ibuprofen, oxycodone, steroid tapers, and oncology-related prescriptions accounted for most free-text prescriptions. A majority of these prescriptions originated from user preference lists. CONCLUSION An interruptive alert was associated with a modest reduction in free-text prescriptions. Furthermore, the majority of these prescriptions could have been reproduced using structured order entry fields. Targeting user preference lists shows promise for future intervention.
Collapse
Affiliation(s)
- Naveed Rabbani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Milan Ho
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas, United States
| | - Debadutta Dash
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Tyler Calway
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Keith Morse
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Whitney Chadwick
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| |
Collapse
|
5
|
Rojas CR, Moore A, Coffin A, McClam C, Ehritz C, Hogan A, Hart J, Galligan MM. Medication Rounds: A Tool to Promote Medication Safety for Children with Medical Complexity. Jt Comm J Qual Patient Saf 2023; 49:226-234. [PMID: 36775713 DOI: 10.1016/j.jcjq.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
Children with medical complexity (CMC) often have lengthy medication lists and are at risk of experiencing suboptimal medication management. This tool tutorial describes a novel and pragmatic strategy for the development and implementation of medication rounds, a model that promotes medication safety for hospitalized CMC. An interprofessional group designed and implemented a pharmacy-led medication rounding care model, in which clinicians and pharmacists partner weekly to conduct reviews of all patient medications on a general pediatrics CMC team using a comprehensive checklist. This approach fosters medication safety for hospitalized CMC and could be adapted to other complex inpatient populations.
Collapse
|
6
|
Schroers G, Ross JG, Moriarty H. Medication administration errors made among undergraduate nursing students: A need for change in teaching methods. J Prof Nurs 2022; 42:26-33. [DOI: 10.1016/j.profnurs.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 11/16/2022]
|
7
|
Factors to predict the knowledge, attitude and practice of nursing interruptions among nurses: A nationwide cross-sectional survey. Nurse Educ Pract 2022; 64:103428. [PMID: 35970094 DOI: 10.1016/j.nepr.2022.103428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/26/2022] [Accepted: 08/07/2022] [Indexed: 11/20/2022]
Abstract
AIM To identify the knowledge, attitude and practice of nursing interruptions and related factors among nurses in China. BACKGROUND Nursing interruptions are extremely common and have introduced major security risks and harm to hospitalized patients. However, nursing interruptions' factors are not well known. DESIGN A nationwide cross-sectional descriptive survey. METHODS A multistratified random sampling method was used to obtain nurses from five provinces in China. We collected data by online questionnaires (the Knowledge, Attitude and Practice Questionnaire of Nursing Interruptions, the Chinese Revised Safety Attitude Questionnaire and the Coping Adaptation Processing Scale). We used the Mann-Whitney test, the Kruskal-Wallis test, Spearman's linear correlation analysis and multiple linear stepwise regression to analyze the data. A STROBE checklist was used to report the results. RESULTS Of the 14500 questionnaires distributed, 14302 (98.6 %) were returned. The mean score was 79.69 (SD 17.73) and the level was medium. Having attended nursing interruptions training and attended nursing safety training, safety attitude, coping ability and position were positive factors, while age and marital status were negative factors (F=1068.226, p < 0.001, R2 =0.374, adjusted R2 =0.373). CONCLUSIONS Chinese nurses expressed a moderate level of knowledge, attitude and practice of nursing interruptions. Safety attitude, having attended nursing interruptions training, coping ability, having attended nursing safety training, position, age and marital status were predictors. RELEVANCE TO CLINICAL PRACTICE Nursing managers should pay attention to the influencing factors of clinical nurses' knowledge, attitude and practice of nursing interruptions and take effective individualized training for clinical nurses with different ages, positions and marital status to improve their coping ability, so as to ensure nursing safety and improve nursing quality.
Collapse
|
8
|
Roumeliotis N, Pullenayegum E, Taddio A, Rochon P, Parshuram C. Liver enzymes after short-term acetaminophen error in critically ill children: a cohort study. Eur J Pediatr 2022; 181:2943-2951. [PMID: 35585255 DOI: 10.1007/s00431-022-04502-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/07/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
UNLABELLED Drug-associated harm is common but difficult to detect in the hospital setting. In critically ill children, we sought to evaluate drug-associated hepatic injury following enteral acetaminophen error, defined as acetaminophen dosing that exceeds daily maximum recommendations. This retrospective cohort study took place in two pediatric intensive care units within a pediatric hospital center. The included patients are children (< 18 years of age) admitted to the pediatric and cardiac intensive care unit between January 2008 and January 2018, and receiving enteral acetaminophen. We defined acetaminophen dosing error as exceeding daily acetaminophen dosing by > 10% the upper limit of maximum recommended dose for weight and age (> 82.5 mg/kg/day or > 4400 mg/day). We included 14,146 admissions, who received 147,485 doses of acetaminophen. Acetaminophen dosing errors occurred 1 in every 9.5 patient-days on acetaminophen. ALT and AST decreased significantly over the course of ICU admission (p < 0.0001). In patients with acetaminophen errors, ALT and AST measured in the 24 to 96 h post error were not significantly different than when measured outside this window. A sensitivity analysis using > 100 mg/kg/day as the upper daily acetaminophen error cut-off did not reveal any subsequent significant increase in ALT or ALT in the 24 to 96-h post-error window, compared to measurements taken outside the window. CONCLUSION Although the administration of acetaminophen in critically ill children frequently exceeds the daily recommended limit and vigilance is needed, we did not find any associated increase in liver transaminases following acetaminophen errors. WHAT IS KNOWN • Acetaminophen dosing errors are common in pediatric outpatients. • Excessive acetaminophen dosing can be associated with harm, including hepatic injury. WHAT IS NEW • Exceeding daily acetaminophen dosing limit occurs 1 in every 9.5 patient-days in children admitted to the critical care unit. • In patients with daily dose excess of acetaminophen, we did not find a significant increase in the measured liver enzymes in the 24 to 96 h following the overdosing.
Collapse
Affiliation(s)
- Nadia Roumeliotis
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada. .,Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, USA. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, USA. .,Department of Pediatrics, CHU Sainte-Justine, 3175 chemin de la Cote-Sainte-Catherine, Montreal, Qc, H3T 1C5, Canada.
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, USA
| | - Anna Taddio
- Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, USA.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, USA
| | - Paula Rochon
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, USA.,Women's College Research Institute, Women's College Hospital, Toronto, ON, USA.,Department of Medicine, University of Toronto, Toronto, ON, USA
| | - Chris Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, USA.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, USA
| |
Collapse
|
9
|
Altamimi MH, Abdelraouf Alfuqaha O, Baniissa AS, AL-Maqbeh WT. Visitors and equipment failure as predictors of interruptions among nurses. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2022. [DOI: 10.15452/cejnm.2021.12.0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
|
10
|
Chaparro JD, Beus JM, Dziorny AC, Hagedorn PA, Hernandez S, Kandaswamy S, Kirkendall ES, McCoy AB, Muthu N, Orenstein EW. Clinical Decision Support Stewardship: Best Practices and Techniques to Monitor and Improve Interruptive Alerts. Appl Clin Inform 2022; 13:560-568. [PMID: 35613913 PMCID: PMC9132737 DOI: 10.1055/s-0042-1748856] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Interruptive clinical decision support systems, both within and outside of electronic health records, are a resource that should be used sparingly and monitored closely. Excessive use of interruptive alerting can quickly lead to alert fatigue and decreased effectiveness and ignoring of alerts. In this review, we discuss the evidence for effective alert stewardship as well as practices and methods we have found useful to assess interruptive alert burden, reduce excessive firings, optimize alert effectiveness, and establish quality governance at our institutions. We also discuss the importance of a holistic view of the alerting ecosystem beyond the electronic health record.
Collapse
Affiliation(s)
- Juan D Chaparro
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, United States.,Departments of Pediatrics and Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Jonathan M Beus
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States.,Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Adam C Dziorny
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, United States
| | - Philip A Hagedorn
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, United States.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Sean Hernandez
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States.,Department of General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Swaminathan Kandaswamy
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Eric S Kirkendall
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States.,Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States.,Center for Biomedical Informatics, Wake Forest School of Medicine, Winston-Salem NC, United States
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Naveen Muthu
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States.,Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| |
Collapse
|
11
|
Abstract
BACKGROUND Near miss medication events are pervasive without patient harm, mostly because of coincidence. Dynamic clinical environments challenge nurse compliance with medication administration rights and proper use of electronic technology. PROBLEM All nurses are educated in appropriate medication management, but our unit's barcoded medication administration scanning and electronic patient identification practices fell below the 97% benchmarks, representing hundreds of near miss medication events each month. APPROACH Transformative leadership guided frontline staff to identify gaps in care processes and determined root causes for unsanctioned medication administration practices using a FOCUS (Find-Organize-Clarify-Understand-Select)-PDSA (Plan-Do-Study-Act) methodology. OUTCOMES An interdisciplinary team committed to zero events of preventable harm overcame challenges to improve care delivery. Medication management scores exceeded organizational benchmarks, with sustainable gains over 2 years. CONCLUSIONS A rapid-cycle, evidence-based approach engaged staff to reduce near miss medication events. Workable solutions driven by transparent communication and interpersonal collaboration influenced positive safety behaviors.
Collapse
|
12
|
Orenstein EW, Kandaswamy S, Muthu N, Chaparro JD, Hagedorn PA, Dziorny AC, Moses A, Hernandez S, Khan A, Huth HB, Beus JM, Kirkendall ES. Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics. J Am Med Inform Assoc 2021; 28:2654-2660. [PMID: 34664664 DOI: 10.1093/jamia/ocab179] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/02/2021] [Accepted: 09/10/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Excessive electronic health record (EHR) alerts reduce the salience of actionable alerts. Little is known about the frequency of interruptive alerts across health systems and how the choice of metric affects which users appear to have the highest alert burden. OBJECTIVE (1) Analyze alert burden by alert type, care setting, provider type, and individual provider across 6 pediatric health systems. (2) Compare alert burden using different metrics. MATERIALS AND METHODS We analyzed interruptive alert firings logged in EHR databases at 6 pediatric health systems from 2016-2019 using 4 metrics: (1) alerts per patient encounter, (2) alerts per inpatient-day, (3) alerts per 100 orders, and (4) alerts per unique clinician days (calendar days with at least 1 EHR log in the system). We assessed intra- and interinstitutional variation and how alert burden rankings differed based on the chosen metric. RESULTS Alert burden varied widely across institutions, ranging from 0.06 to 0.76 firings per encounter, 0.22 to 1.06 firings per inpatient-day, 0.98 to 17.42 per 100 orders, and 0.08 to 3.34 firings per clinician day logged in the EHR. Custom alerts accounted for the greatest burden at all 6 sites. The rank order of institutions by alert burden was similar regardless of which alert burden metric was chosen. Within institutions, the alert burden metric choice substantially affected which provider types and care settings appeared to experience the highest alert burden. CONCLUSION Estimates of the clinical areas with highest alert burden varied substantially by institution and based on the metric used.
Collapse
Affiliation(s)
- Evan W Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Naveen Muthu
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juan D Chaparro
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Philip A Hagedorn
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam C Dziorny
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York, USA.,Division of Critical Care Medicine, Golisano Children's Hospital at Strong, Rochester, New York, USA
| | - Adam Moses
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sean Hernandez
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of General Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Amina Khan
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hannah B Huth
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jonathan M Beus
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric S Kirkendall
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
13
|
Rasooly IR, Kern-Goldberger AS, Xiao R, Ponnala S, Ruppel H, Luo B, Craig S, Khan A, McLoone M, Ferro D, Muthu N, Won J, Bonafide CP. Physiologic Monitor Alarm Burden and Nurses' Subjective Workload in a Children's Hospital. Hosp Pediatr 2021; 11:703-710. [PMID: 34074710 PMCID: PMC8478695 DOI: 10.1542/hpeds.2020-003509] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Physiologic monitor alarms occur at high rates in children's hospitals; ≤1% are actionable. The burden of alarms has implications for patient safety and is challenging to measure directly. Nurse workload, measured by using a version of the National Aeronautics and Space Administration Task Load Index (NASA-TLX) validated among nurses, is a useful indicator of work burden that has been associated with patient outcomes. A recent study revealed that 5-point increases in the NASA-TLX score were associated with a 22% increased risk in missed nursing care. Our objective was to measure the relationship between alarm count and nurse workload by using the NASA-TLX. METHODS We conducted a repeated cross-sectional study of pediatric nurses in a tertiary care children's hospital to measure the association between NASA-TLX workload evaluations (using the nurse-validated scale) and alarm count in the 2 hours preceding NASA-TLX administration. Using a multivariable mixed-effects regression accounting for nurse-level clustering, we modeled the adjusted association of alarm count with workload. RESULTS The NASA-TLX score was assessed in 26 nurses during 394 nursing shifts over a 2-month period. In adjusted regression models, experiencing >40 alarms in the preceding 2 hours was associated with a 5.5 point increase (95% confidence interval 5.2 to 5.7; P < .001) in subjective workload. CONCLUSION Alarm count in the preceding 2 hours is associated with a significant increase in subjective nurse workload that exceeds the threshold associated with increased risk of missed nursing care and potential patient harm.
Collapse
Affiliation(s)
- Irit R Rasooly
- Section of Pediatric Hospital Medicine
- Departments of Biomedical and Health Informatics
- Centers for Pediatric Clinical Effectiveness
- Departments of Pediatrics
| | | | - Rui Xiao
- Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | - Halley Ruppel
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brooke Luo
- Section of Pediatric Hospital Medicine
- Departments of Biomedical and Health Informatics
- Departments of Pediatrics
| | - Sansanee Craig
- Departments of Biomedical and Health Informatics
- Departments of Pediatrics
| | | | - Melissa McLoone
- Nursing Practice and Education, Children's Hospital of Philadelphia, Philadelphia
| | - Daria Ferro
- Section of Pediatric Hospital Medicine
- Departments of Biomedical and Health Informatics
- Departments of Pediatrics
| | - Naveen Muthu
- Section of Pediatric Hospital Medicine
- Departments of Biomedical and Health Informatics
- Departments of Pediatrics
| | - James Won
- Departments of Pediatrics
- Healthcare Quality and Analytics
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine
- Departments of Biomedical and Health Informatics
- Centers for Pediatric Clinical Effectiveness
- Departments of Pediatrics
| |
Collapse
|
14
|
Schnitzler ER, Schneck MJ. Therapeutic Pitfalls in the Transition of Neurologic Patients from Pediatric to Adult Health Care Providers. Neurol Clin 2020; 39:243-256. [PMID: 33223087 DOI: 10.1016/j.ncl.2020.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Transitions of care from the pediatric to adult setting are fraught with difficulty. For patients whose neurologic problems began in childhood, there is often a lack of organized multidisciplinary care with the desired neurologic expertise in the adult setting. This monograph highlights those difficulties, reviewing disease-specific instances of the problems with transition from pediatric to adult neurologic care. The use of an arbitrary chronologic age cutoff for transition from pediatric to adult expertise in specific disease state may be a disservice in provision of care, and the disease-specific expertise of providers may outweigh the benefit of an age-related provider focus.
Collapse
Affiliation(s)
- Eugene R Schnitzler
- Department of Neurology, Division of Pediatric Neurology, Loyola University Chicago, Stritch School of Medicine, Maguire Building Suite 2700, 2160 South First Avenue, Maywood, IL 60153, USA; Department of Pediatrics, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA; Department of Neurosurgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| |
Collapse
|
15
|
Schroers G, Ross JG, Moriarty H. Nurses' Perceived Causes of Medication Administration Errors: A Qualitative Systematic Review. Jt Comm J Qual Patient Saf 2020; 47:S1553-7250(20)30247-6. [PMID: 33153914 DOI: 10.1016/j.jcjq.2020.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Medication administration errors (MAEs) are a critical patient safety issue. Nurses are often responsible for administering medication to patients, thus their perceptions of causes of errors can provide valuable guidance for the development of interventions aimed to mitigate errors. Quantitative research can overlook less overt causes; therefore, a qualitative systematic review was conducted to present a synthesis of qualitative evidence of nurses' perceived causes of MAEs. METHODS Publications from 2000 to February 2019 were searched using four electronic databases. Inclusion criteria were articles that (1) presented results from studies that used a qualitative or mixed methods design, (2) reported qualitative data on nurses' perceived causes of MAEs in health care settings, and (3) were published in the English language. Sixteen individual articles satisfied the inclusion criteria. Methodological quality of each article was assessed using the Critical Appraisal Skills Programme (CASP) tool. Thematic analysis of the data was performed. Perceived causes of errors were labeled as knowledge-based, personal, and contextual factors. RESULTS The primary knowledge-based factor was lack of medication knowledge. Personal factors included fatigue and complacency. Contextual factors included heavy workloads and interruptions. Contextual factors were reported in all the studies reviewed and were often interconnected with personal and knowledge-based factors. CONCLUSION Causes of MAEs are perceived by nurses to be multifactorial and interconnected and often stem from systems issues. Multifactorial interventions aimed at mitigating medication errors are required with an emphasis on systems changes. Findings in this review can be used to guide efforts aimed at identifying and modifying factors contributing to MAEs.
Collapse
|
16
|
Ruppel H, Bonafide CP. Sounds good: the bright future of clinical alarm management initiatives. BMJ Qual Saf 2020; 29:701-703. [PMID: 32086299 PMCID: PMC7442598 DOI: 10.1136/bmjqs-2019-010561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Halley Ruppel
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|