The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors

Clinical Considerations for Rapid Administration of Undiluted or Minimally Diluted Levetiracetam Bolus Doses

INTRODUCTION

The ability to administer medications via rapid intravenous bolus has the potential to allow for the rapid attainment of therapeutic drug levels and to limit the amount of unnecessary fluid volumes infused. The purpose of this review was to evaluate the efficacy and safety of undiluted or minimally diluted levetiracetam bolus doses.

AREAS COVERED

A total of six pieces of literature were evaluated in this review. Doses up to 4,500 mg of intravenous levetiracetam were found to be both efficacious and safe when administered undiluted or minimally diluted in either a peripheral or central line. Product concentrations of levetiracetam ranged from 50 mg/mL to 100 mg/mL, with volumes ranging from 10-30 mL's. Maintenance doses of up to 1,500 mg twice daily were demonstrated to be both efficacious and safe when administered undiluted or minimally diluted. Injection site pain and agitation were the most commonly reported adverse drug effects.

EXPERT OPINION

Though hospitals and clinicians must be judicious with regard to training and the safety concerns of bolus intravenous push doses, and will need to address numerous logistical concerns, this practice is supported in practice guidelines and should be readily employed.

Intravenous Smart Pump Drug Library Compliance: A Descriptive Study of 44 Hospitals

BACKGROUND

Although intravenous (IV) smart pumps with built-in dose-error reduction systems (DERS) can reduce IV medication administration error, most serious adverse events still occur during IV medication administration. Sources of error include overriding DERS and manually bypassing drug libraries and the DERS.

METHODS

Our purpose was to use the Regenstrief National Center for Medical Device Informatics data set to better understand IV smart pump drug library and DERS compliance. Our sample consisted of 12 months of data from 7 hospital systems, 44 individual hospitals, and descriptive data from the American Hospital Directory (AHD) for 2015. The aims of the study were (1) to determine whether there are differences in IV smart pump drug library compliance between hospital systems and (2) to provide a broad descriptive overview of relevant trends related to IV smart pump compliance.

RESULTS

For aim 1, we found 3 significant relationships among the 7 hospital systems: systems 3 (P < 0.001), 6 (P = 0.003), and 7 (P = 0.002) had significantly higher IV smart compliance as compared with system 4. For aim 2, the number of drug library profiles was positively correlated (P = 0.029) with IV smart pump compliance and the IV smart pump type used was significantly correlated (P = 0.013) with IV smart pump compliance.

CONCLUSIONS

Our findings support that there are differences in IV smart pump compliance both within and between hospital systems and that IV smart pump type and the number of drug library profiles may be influencing factors. Further research is required to more accurately identify the impact of these factors in this very important area of patient safety.

Health information technology implementation - impacts and policy considerations: a comparison between Israel and Portugal

The use of Information and Communications Technology (ICT) in health systems is increasing worldwide. While it is assumed that ICT holds great potential to make health services more efficient and grant patients more empowerment, research on these trends is at an early stage. Building on a study of the impact of ICT on physicians and patients in Israel, a Short Term Scientific Mission (STSM) sponsored by COST Net in conjunction with CIES/ISCTE IUL (Portugal) facilitated a comparison of ICT in health in Israel and Portugal. The comparison focused on patient empowerment, physician behavior and the role of government in implementing ICT. The research in both countries was qualitative in nature. In-depth interviews with the Ministry of Health (MOH), the private sector, patients associations, health plans and researchers were used to collect data. Purposeful sampling was used to select respondents, and secondary sources were used for triangulation. The findings indicate that respondents in both countries feel that patient empowerment has indeed been furthered by introduction of ICT. Regarding physicians, in both countries ICT is seen as providing more information that can be used in medical decision making. Increased access of patients to web-based medical information can strengthen the role of patients in decision making and improve the physician-patient relationship, but also shift the latter in ways that may require adjustments in physician orientation. Physician uptake of ICT in both countries involves overcoming certain barriers, such as resistance to change. At the national level, important differences were found between the two countries. While in Israel, ICT was promoted and adopted by the meso level of the health system, in particular the health plans and government intervention can be found in a later stage, in Portugal the government was the main developer and national strategies were built from the beginning. These two approaches present different advantages and disadvantages. Government involvement in earlier stages could provide benefit in terms of interoperability of systems between different healthcare organizations. However, innovation could be slowed down due to government bureaucracy or lack of leadership. The work provides information in order to understand and improve ICT services. Additionally, it provides input regarding impact of ICT on the physician/patient relationship and national policies in the area.

Effectiveness of Evidence-based Pneumonia CPOE Order Sets Measured by Health Outcomes

Objective

Evidence-based sets of medical orders for the treatment of patients with common conditions have the potential to induce greater efficiency and convenience across the system, along with more consistent health outcomes. Despite ongoing utilization of order sets, quantitative evidence of their effectiveness is lacking. In this study, conducted at Advocate Health Care in Illinois, we quantitatively analyzed the benefits of community acquired pneumonia order sets as measured by mortality, readmission, and length of stay (LOS) outcomes.

Methods

In this study, we examined five years (2007–2011) of computerized physician order entry (CPOE) data from two city and two suburban community care hospitals. Mortality and readmissions benefits were analyzed by comparing “order set” and “no order set” groups of adult patients using logistic regression, Pearson’s chi-squared, and Fisher’s exact methods. LOS was calculated by applying one-way ANOVA and the Mann-Whitney U test, supplemented by analysis of comorbidity via the Charlson Comorbidity Index.

Results

The results indicate that patient treatment orders placed via electronic sets were effective in reducing mortality [OR=1.787; 95% CF 1.170-2.730; P=.061], readmissions [OR=1.362; 95% CF 1.015-1.827; P=.039], and LOS [F (1,5087)=6.885, P=.009, 4.79 days (no order set group) vs. 4.32 days (order set group)].

Conclusion

Evidence-based ordering practices have the potential to improve pneumonia outcomes through reduction of mortality, hospital readmissions, and cost of care. However, the practice must be part of a larger strategic effort to reduce variability in patient care processes. Further experimental and/or observational studies are required to reduce the barriers to retrospective patient care analyses.

Analysis of health professional security behaviors in a real clinical setting: an empirical study

OBJECTIVE

The objective of this paper is to evaluate the security behavior of healthcare professionals in a real clinical setting.

METHOD

Standards, guidelines and recommendations on security and privacy best practices for staff personnel were identified using a systematic literature review. After a revision process, a questionnaire consisting of 27 questions was created and responded to by 180 health professionals from a public hospital.

RESULTS

Weak passwords were reported by 62.2% of the respondents, 31.7% were unaware of the organization's procedures for discarding confidential information, and 19.4% did not carry out these procedures. Half of the respondents (51.7%) did not take measures to ensure that the personal health information on the computer monitor could not be seen by unauthorized individuals, and 57.8% were unaware of the procedure established to report a security violation. The correlation between the number of years in the position and good security practices was not significant (Pearson's r=0.085, P=0.254). Age was weakly correlated with good security practices (Pearson's r=-0.169, P=0.028). A Mann-Whitney test showed no significant difference between the respondents' security behavior as regards gender (U=2536, P=0.792, n=178). The results of the study suggest that more efforts are required to improve security education for health personnel.

CONCLUSIONS

It was found that both preventive and corrective actions are needed to prevent health staff from causing security incidents. Healthcare organizations should: identify the types of information that require protection, clearly communicate the penalties that will be imposed, promote security training courses, and define what the organization considers improper behavior to be and communicate this to all personnel.

Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study

OBJECTIVE

To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction.

METHODS

Controlled pre-post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession.

RESULTS

eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001).

CONCLUSIONS

eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.

Security and privacy in electronic health records: a systematic literature review

OBJECTIVE

To report the results of a systematic literature review concerning the security and privacy of electronic health record (EHR) systems.

DATA SOURCES

Original articles written in English found in MEDLINE, ACM Digital Library, Wiley InterScience, IEEE Digital Library, Science@Direct, MetaPress, ERIC, CINAHL and Trip Database.

STUDY SELECTION

Only those articles dealing with the security and privacy of EHR systems.

DATA EXTRACTION

The extraction of 775 articles using a predefined search string, the outcome of which was reviewed by three authors and checked by a fourth.

RESULTS

A total of 49 articles were selected, of which 26 used standards or regulations related to the privacy and security of EHR data. The most widely used regulations are the Health Insurance Portability and Accountability Act (HIPAA) and the European Data Protection Directive 95/46/EC. We found 23 articles that used symmetric key and/or asymmetric key schemes and 13 articles that employed the pseudo anonymity technique in EHR systems. A total of 11 articles propose the use of a digital signature scheme based on PKI (Public Key Infrastructure) and 13 articles propose a login/password (seven of them combined with a digital certificate or PIN) for authentication. The preferred access control model appears to be Role-Based Access Control (RBAC), since it is used in 27 studies. Ten of these studies discuss who should define the EHR systems' roles. Eleven studies discuss who should provide access to EHR data: patients or health entities. Sixteen of the articles reviewed indicate that it is necessary to override defined access policies in the case of an emergency. In 25 articles an audit-log of the system is produced. Only four studies mention that system users and/or health staff should be trained in security and privacy.

CONCLUSIONS

Recent years have witnessed the design of standards and the promulgation of directives concerning security and privacy in EHR systems. However, more work should be done to adopt these regulations and to deploy secure EHR systems.

Changing patient care orders from paper to computerized provider order entry-based process

The purpose of this study was to describe the extent of change in patient care orders primarily for six diagnoses, procedures, or conditions in a not-for-profit Midwestern rural referral hospital. A descriptive method was used to analyze changes in the order sets over time for chest pain with acute myocardial infarction, degenerative osteoarthritis with hip joint replacement and degenerative osteoarthritis with knee joint replacement procedures, coronary artery bypass graft procedures, congestive heart failure, and pneumonia. Ten items about service-specific order sets were abstracted during pre- and post-EHR implementation and a year later. We then examined use 5 years later. The findings illustrate how the order sets evolved with multiple nested order sets to facilitate computerized provider order entry with a rate greater than 70% by physicians. The total number of available patient care orders within the order sets increased primarily because of linked nested order sets related to medications and diagnostic tests. Five years later, 50% of the orders were medication orders. In conclusion, this was important to deploy the order sets within smaller critical-access hospital facilities to train providers in adopting order sets internally.

An analysis of the development and implementation of a smartphone application for the delivery of antimicrobial prescribing policy: lessons learnt

Objectives

Smartphone usage amongst clinicians is widespread. Yet smartphones are not widely used for the dissemination of policy or as clinical decision support systems. We report here on the development, adoption and implementation process of the Imperial Antimicrobial Prescribing Application across five teaching hospitals in London.

Methods

Doctors and clinical pharmacists were recruited to this study, which employed a mixed methods in-depth case-study design with focus groups, structured pre- and post-intervention survey questionnaires and live data on application uptake. The primary outcome measure was uptake of the application by doctors and its acceptability. The development and implementation processes were also mapped.

Results

The application was downloaded by 40% (376) of junior doctors with smartphones (primary target user group) within the first month and by 100% within 12 months. There was an average of 1900 individual access sessions per month, compared with 221 hits on the Intranet version of the policy. Clinicians (71%) reported that using the application improved their antibiotic knowledge.

Conclusions

Clinicians rapidly adopted the mobile application for antimicrobial prescribing at the point of care, enabling the policy to reach a much wider audience in comparison with paper- and desktop-based versions of the policy. Organizations seeking to optimize antimicrobial prescribing should consider utilizing mobile technology to deliver point-of-care decision support. The process revealed a series of barriers, which will need to be addressed at individual and organizational levels to ensure safe and high-quality delivery of local policy at the point of care.

Exploring the Effect of mHealth Technologies on Communication and Information Sharing in a Pediatric Critical Care Unit

Communication and information sharing is an important aspect of healthcare information technology and mHealth management. A main requirement in the quality of patient care is the ability of all health care participants to communicate. Research illustrates that the complexity of communicating within the health care system hinders the quality of health care service delivery. Health informatics have been touted as a way to improve communication deficiencies, which has led to the exponential growth of health informatics integration. However, research still lags in understanding how health informatics affects patient care, health professional work routines, and the overall health care system. This study investigates the extent to which mHealth technologies influence communication information sharing patterns between interdisciplinary health care providers in the delivery of health care services. This study was conducted at Hamilton Health Sciences and through a sociotechnical approach, focuses on both the end user’s experiences with mHealth in daily work communication scenarios, and the extent to which mHealth use affects interdisciplinary communication. Results indicate that there are several mitigating factors which influence communication patterns using mHealth technologies, including: information sharing, mobility, ergonomic and system design.

Feedback GAP: study protocol for a cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care

BACKGROUND

Audit and feedback to physicians is commonly used alone or as part of multifaceted interventions. While it can play an important role in quality improvement, the optimal design of audit and feedback is unknown. This study explores how feedback can be improved to increase acceptability and usability in primary care. The trial seeks to determine whether a theory-informed worksheet appended to feedback reports can help family physicians improve quality of care for their patients with diabetes and/or ischemic heart disease.

METHODS

Two-arm cluster trial was conducted with participating primary care practices allocated using minimization to simple feedback or enhanced feedback group. The simple feedback group receives performance feedback reports every six months for two years regarding the proportion of their patients with diabetes and/or ischemic heart disease who are meeting quality targets. The enhanced feedback group receives these same reports as well as a theory-informed worksheet designed to facilitate goal setting and action plan development in response to the feedback reports. Participants are family physicians from across Ontario who use electronic medical records; data for rostered patients are used to produce the feedback reports and for analysis.

OUTCOMES

The primary disease outcomes are the blood pressure (BP), and low-density lipoprotein cholesterol (LDL) levels. The primary process measure is a composite score indicating the number of recommended activities (e.g., tests and prescriptions) conducted by the family physicians for their patients with diabetes and/or ischemic heart disease within the appropriate timeframe. Secondary outcomes are the proportion of patients whose results meet targets for glucose, LDL, and BP as well as the percent of patients receiving relevant prescriptions. A qualitative process evaluation using semi-structured interviews will explore perceived barriers to behaviour change in response to feedback reports and preferences with regard to feedback design.

ANALYSIS

Intention-to-treat approach will be used to analyze the trial. Analysis will be performed on patient-level variables using generalized estimating equation models to adjust for covariates and account for the clustered nature of the data. The trial is powered to show small, but clinically important differences of 7 mmHG in systolic BP and 0.32 mmol/L in LDL.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00996645.

Clinician perceptions of an electronic medical record during the first year of implementaton in emergency services

OBJECTIVES

The objectives of this study were to measure clinician perceptions of the recently implemented electronic medical record (EMR) system in a pediatric emergency department and off-site urgent care centers and to determine how user perceptions changed over time.

METHODS

Physicians and nurses from the emergency department/urgent care center were recruited to complete an online survey at 3 points in time: 30 to 89 days (wave 1), 90 to 179 days (wave 2), and 180 to 270 days after implementation (wave 3). Potential predictors of initial satisfaction studied included effort expectancy, performance expectancy, social support, and facilitating conditions, along with user demographics and general attitudes toward technology. Bivariate relationships with satisfaction were assessed using the Wilcoxon rank sum test and correlation analysis. A final multivariate linear regression model was calculated. Change in satisfaction over time was tested using a Wilcoxon signed rank test.

RESULTS

A total of 71 clinicians completed the surveys. Initial satisfaction was strongly associated with perceptions of training and support (facilitating conditions) and with perceived usefulness (performance expectancy). Satisfaction was not associated with user sex, age, or role (physician vs nurse). No significant change was found in any satisfaction measure at wave 2 or 3; however, satisfaction with functionality trended higher and satisfaction with reliability trended lower over the course of use.

CONCLUSIONS

Satisfaction with an EMR at its launch generally persisted through the first year of use. Implementation plans must maximize the likelihood of achieving positive early impressions of training, support, and performance to engender high user satisfaction with the EMR.

The health information system security threat lifecycle: an informatics theory

PURPOSE

This manuscript describes the health information system security threat lifecycle (HISSTL) theory. The theory is grounded in case study data analyzing clinicians' health information system (HIS) privacy and security (P&S) experiences in the practice context.

METHODS

The 'questerview' technique was applied to this study of 26 clinicians situated in 3 large Australian (across Victoria) teaching hospitals. Questerviews rely on data collection that apply standardized questions and questionnaires during recorded interviews. Analysis (using Nvivo) involved the iterative scrutiny of interview transcripts to identify emergent themes.

RESULTS

Issues including poor training, ambiguous legal frameworks containing punitive threats, productivity challenges, usability errors and the limitations of the natural hospital environment emerged from empirical data about the clinicians' HIS P&S practices. The natural hospital environment is defined by the permanence of electronic HISs (e-HISs), shared workspaces, outdated HIT infrastructure, constant interruption, a P&S regulatory environment that is not conducive to optimal training outcomes and budgetary constraints. The evidence also indicated the obtrusiveness, timeliness, and reliability of P&S implementations for clinical work affected participant attitudes to, and use of, e-HISs.

CONCLUSION

The HISSTL emerged from the analysis of study evidence. The theory embodies elements such as the fiscal, regulatory and natural hospital environments which impede P&S implementations in practice settings. These elements conflict with improved patient care outcomes. Efforts by clinicians to avoid conflict and emphasize patient care above P&S tended to manifest as security breaches. These breaches entrench factors beyond clinician control and perpetuate those within clinician control. Security breaches of health information can progress through the HISSTL. Some preliminary suggestions for addressing these issues are proposed.

STUDY LIMITATIONS

Legislative frameworks that are not related to direct patient care were excluded from this study. Other limitations included an exclusive focus on patient care tasks post-admission and pre-discharge from public hospital wards. Finally, the number of cases was limited by the number of participants who volunteered to participate in the study. It is reasonable to assume these participants were more interested in the P&S of patient care work than their counterparts, though the study was not intended to provide quantitative or statistical data. Nonetheless, additional case studies would strengthen the HISSTL theory if confirmatory, practice-based evidence were found.

The effect of Computerized Physician Order Entry and decision support system on medication errors in the neonatal ward: experiences from an Iranian teaching hospital

Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three periods to compare the effect of Computerized Physician Order Entry (CPOE) without and with decision support functionalities in reducing non-intercepted medication dosing errors in antibiotics and anticonvulsants. Before intervention (Period 1), error rate was 53%, which did not significantly change after the implementation of CPOE without decision support (Period 2). However, errors were significantly reduced to 34% after that the decision support was added to the CPOE (Period 3; P < 0.001). Dose errors were more often intercepted than frequency errors. Over-dose was the most frequent type of medication errors and curtailed-interval was the least. Transcription errors did not reduce after the CPOE implementation. Physicians ignored alerts when they could not understand why they appeared. A suggestion is to add explanations about these reasons to increase physicians' compliance with the system's recommendations.

A novel method to link and validate routinely collected emergency department clinical data to measure quality of care

The objective was to develop and validate a method to link routinely captured electronic data for the measurement of emergency department (ED) quality indicators. Electronic ED data were linked to calculate time to antibiotics and time to electrocardiogram (ECG) for pneumonia and chest pain patients, respectively; validation was by comparison with chart data. Linked electronic data correctly identified 40/40 pneumonia and 65/65 chest pain patients. The median difference in time to antibiotics calculated from linked electronic data versus chart data was 6 minutes (standard deviation [SD] = 14.0); for time to ECG it was 0 minutes (SD = 70). The percentage of ED patients meeting target time to antibiotics was 47% with electronic data versus 44% with charts; for time to ECG, 8% met target time with electronic data versus 11% with charts. A simple computer algorithm for linking routine ED electronic data for quality-of-care measurement was validated.

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration

OBJECTIVE

To describe the foci, activities, methods, and results of a 4-year research project identifying the unintended consequences of computerized provider order entry (CPOE).

METHODS

Using a mixed methods approach, we identified and categorized into nine types 380 examples of the unintended consequences of CPOE gleaned from fieldwork data and a conference of experts. We then conducted a national survey in the U.S.A. to discover how hospitals with varying levels of infusion, a measure of CPOE sophistication, recognize and deal with unintended consequences. The research team, with assistance from experts, identified strategies for managing the nine types of unintended adverse consequences and developed and disseminated tools for CPOE implementers to help in addressing these consequences.

RESULTS

Hospitals reported that levels of infusion are quite high and that these types of unintended consequences are common. Strategies for avoiding or managing the unintended consequences are similar to best practices for CPOE success published in the literature.

CONCLUSION

Development of a taxonomy of types of unintended adverse consequences of CPOE using qualitative methods allowed us to craft a national survey and discover how widespread these consequences are. Using mixed methods, we were able to structure an approach for addressing the skillful management of unintended consequences as well.

CPOE in Iran--a viable prospect? Physicians' opinions on using CPOE in an Iranian teaching hospital

BACKGROUND

In recent years, the theory that on-line clinical decision support systems can improve patients' safety among hospitalised individuals has gained greater acceptance. However, the feasibility of implementing such a system in a middle or low-income country has rarely been studied. Understanding the current prescription process and a proper needs assessment of prescribers can act as the key to successful implementation.

OBJECTIVES

The aim of this study was to explore physicians' opinions on the current prescription process, and the expected benefits and perceived obstacles to employ Computerised Physician Order Entry in an Iranian teaching hospital.

METHODS

Initially, the interview guideline was developed through focus group discussions with eight experts. Then semi-structured interviews were held with 19 prescribers. After verbatim transcription, inductive thematic analysis was performed on empirical data. Forty hours of on-looker observations were performed in different wards to explore the current prescription process.

RESULTS

The current prescription process was identified as a physician-centred, top-down, model, where prescribers were found to mostly rely on their memories as well as being overconfident. Some errors may occur during different paper-based registrations, transcriptions and transfers. Physician opinions on Computerised Physician Order Entry were categorised into expected benefits and perceived obstacles. Confidentiality issues, reduction of medication errors and educational benefits were identified as three themes in the expected benefits category. High cost, social and cultural barriers, data entry time and problems with technical support emerged as four themes in the perceived obstacles category.

CONCLUSIONS

The current prescription process has a high possibility of medication errors. Although there are different barriers confronting the implementation and continuation of Computerised Physician Order Entry in Iranian hospitals, physicians have a willingness to use them if these systems provide significant benefits. A pilot study in a limited setting and a comprehensive analysis of health outcomes and economic indicators should be performed, to assess the merits of introducing Computerised Physician Order Entry with decision support capabilities in Iran.

The nature and occurrence of registration errors in the emergency department

Research into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED), where the focus of clinical decisions is on the timely evaluation and stabilization of patients. This paper reports on the nature of errors and their implications for patient safety in an adult ED, using methods of ethnographic observation, interviews, and think-aloud protocols. Data were analyzed using modified "grounded theory," which refers to a theory developed inductively from a body of data. Analysis revealed four classes of errors, relating to errors of misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and in one case, switching of one patient's identification information with those of another. Further analysis traced the root of the errors to ED registration. These results indicate that the nature of errors in the emergency department are complex, multi-layered and result from an intertwined web of activity, in which stress in the work environment, high patient volume and the tendency to adopt shortcuts play a significant role. The need for information technology (IT) solutions to these problems as well as the impact of alternative policies is discussed.