S. Wachter, J. Agutter, Noah Syroid, F. Drews, D. Westenskow
The anesthesiologist is faced with a fire-hose of information in the operating room. Data from the patient monitors include numerical data, waveforms, control settings, and alarm conditions. During an unexpected event, the anesthesiologist must quickly assess available information in order to diagnose and treat the patient before the patient is injured. However, human error is associated with more than 80% of critical anesthesia incidents and more than 50% of anesthetic deaths.1 In a recent study at the University of Washington, Department of Anesthesiology, 32% of the reported human error incidents were related …
{"title":"Poster Abstract: A New Metaphor to Display Critical Pulmonary Events during Anesthesia","authors":"S. Wachter, J. Agutter, Noah Syroid, F. Drews, D. Westenskow","doi":"10.1197/JAMIA.M1239","DOIUrl":"https://doi.org/10.1197/JAMIA.M1239","url":null,"abstract":"The anesthesiologist is faced with a fire-hose of information in the operating room. Data from the patient monitors include numerical data, waveforms, control settings, and alarm conditions. During an unexpected event, the anesthesiologist must quickly assess available information in order to diagnose and treat the patient before the patient is injured. However, human error is associated with more than 80% of critical anesthesia incidents and more than 50% of anesthetic deaths.1 In a recent study at the University of Washington, Department of Anesthesiology, 32% of the reported human error incidents were related …","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"7 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121303805","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In 1998, the Institute of Medicine (IOM) issued a report on medical errors, which estimated that up to 98,000 people die in U.S. hospitals each year from errors. This report raised concerns that medical errors have become a national public health problem that should be addressed in the same manner as other epidemics such as heart disease, diabetes, and obesity. In 2001, the IOM released a follow-up report encompassing a broader range of quality issues. They concluded that the U.S. healthcare system is outmoded and incapable of providing consistent, high-quality care. They outlined a strategy for redesigning U.S. healthcare delivery to achieve safe, dependable, high-quality care, which emphasizes information technology as an integral part of the solution. AHRQ's fiscal year 2001 appropriation included $50 million dollars for initiatives to reduce medical errors and improve patient safety. AHRQ responded to this mandate by developing a series of research solicitations that form an integrated set of activities to design and test best practices for reducing errors in multiple health care settings. This paper discusses the components of this program and the central role of medical informatics research in the Agency's efforts to improve the safety of medical care in America.
{"title":"Clinical Informatics and Patient Safety at the Agency for Healthcare Research and Quality","authors":"E. Ortiz, G. Meyer, H. Burstin","doi":"10.1197/JAMIA.M1216","DOIUrl":"https://doi.org/10.1197/JAMIA.M1216","url":null,"abstract":"In 1998, the Institute of Medicine (IOM) issued a report on medical errors, which estimated that up to 98,000 people die in U.S. hospitals each year from errors. This report raised concerns that medical errors have become a national public health problem that should be addressed in the same manner as other epidemics such as heart disease, diabetes, and obesity. In 2001, the IOM released a follow-up report encompassing a broader range of quality issues. They concluded that the U.S. healthcare system is outmoded and incapable of providing consistent, high-quality care. They outlined a strategy for redesigning U.S. healthcare delivery to achieve safe, dependable, high-quality care, which emphasizes information technology as an integral part of the solution. AHRQ's fiscal year 2001 appropriation included $50 million dollars for initiatives to reduce medical errors and improve patient safety. AHRQ responded to this mandate by developing a series of research solicitations that form an integrated set of activities to design and test best practices for reducing errors in multiple health care settings. This paper discusses the components of this program and the central role of medical informatics research in the Agency's efforts to improve the safety of medical care in America.","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123446821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We have established that inadequate access to timely information and ineffective communication among patient care team members are frequent events that are proximal causes of medical errors.1 We are exploring the use of wireless mobile computing technology to help reduce these problems through extensions to the Web-based clinical information system at New York Presbyterian Hospital (NYPH). Currently, there are several wireless devices that allow Web browsing and e-mail messaging along with other features. The advantage of Palm devices over other personal digital assistants (PDA) is size and the enormous amount of software available for the Palm OS. Compared to cellular phones and alphanumeric pagers, …
{"title":"Poster Abstract: Use of Wireless Technology for Reducing Medical Errors","authors":"Elizabeth S. Chen, J. Cimino","doi":"10.1197/JAMIA.M1245","DOIUrl":"https://doi.org/10.1197/JAMIA.M1245","url":null,"abstract":"We have established that inadequate access to timely information and ineffective communication among patient care team members are frequent events that are proximal causes of medical errors.1 We are exploring the use of wireless mobile computing technology to help reduce these problems through extensions to the Web-based clinical information system at New York Presbyterian Hospital (NYPH).\u0000\u0000Currently, there are several wireless devices that allow Web browsing and e-mail messaging along with other features. The advantage of Palm devices over other personal digital assistants (PDA) is size and the enormous amount of software available for the Palm OS. Compared to cellular phones and alphanumeric pagers, …","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"109 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122417209","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Peterson, Deborah H. Williams, A. Seger, T. Gandhi, D. Bates
Previous studies have found that many adverse drug events (ADEs) in inpatients can be detected or prevented by alerting physicians to measured physiologic parameters such as an elevated creatinine or hyperkalemia.1,2 In developing a decision support system for an outpatient Electronic Medical Record, we have begun to retrospectively study associations between drugs and labs that could trigger an alert to physicians. …
{"title":"Poster Abstract: Drug-Lab Triggers Have Potential to Prevent Adverse Drug Events in Outpatients","authors":"J. Peterson, Deborah H. Williams, A. Seger, T. Gandhi, D. Bates","doi":"10.1197/JAMIA.M1223","DOIUrl":"https://doi.org/10.1197/JAMIA.M1223","url":null,"abstract":"Previous studies have found that many adverse drug events (ADEs) in inpatients can be detected or prevented by alerting physicians to measured physiologic parameters such as an elevated creatinine or hyperkalemia.1,2 In developing a decision support system for an outpatient Electronic Medical Record, we have begun to retrospectively study associations between drugs and labs that could trigger an alert to physicians. …","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"10 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126127914","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ying-Chou Sun, D. Tang, Q. Zeng-Treitler, R. Greenes
When a typographic error of a patient identification number occurs on a patient document such as an envelope for radiology films or the cover of a patient record, it will result in misplacement of the document. Once misplaced, such documents are often extremely difficult to recover. After analyzing 290 numerical typos, we found that errors do not occur randomly. Instead, many of the typos share certain specific patterns. Six major types of non-random numeral typographic error patterns have been identified and their frequency characterized. Knowing these patterns and their odds increases the likelihood of finding a misplaced file. In addition, awareness of these patterns during transcribing or writing a patient ID may decrease the chance of typographic errors.
{"title":"Poster Abstract: Identification of Special Patterns of Numerical Typographic Errors Increases the Likelihood of Finding a Misplaced Patient File","authors":"Ying-Chou Sun, D. Tang, Q. Zeng-Treitler, R. Greenes","doi":"10.1197/JAMIA.M1233","DOIUrl":"https://doi.org/10.1197/JAMIA.M1233","url":null,"abstract":"When a typographic error of a patient identification number occurs on a patient document such as an envelope for radiology films or the cover of a patient record, it will result in misplacement of the document. Once misplaced, such documents are often extremely difficult to recover. After analyzing 290 numerical typos, we found that errors do not occur randomly. Instead, many of the typos share certain specific patterns. Six major types of non-random numeral typographic error patterns have been identified and their frequency characterized. Knowing these patterns and their odds increases the likelihood of finding a misplaced file. In addition, awareness of these patterns during transcribing or writing a patient ID may decrease the chance of typographic errors.","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129676656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Drawing software from Lassalle Technologies1 (France) designed for Visual Basic is the tool we used to standardize the creation, storage, and retrieval of flow diagrams containing information about adverse events and close calls.
{"title":"Poster Abstract: Patient Safety - Incorporating Drawing Software into Root Cause Analysis Software","authors":"Linda Williams, Diana Grayson, J. Gosbee","doi":"10.1197/JAMIA.M1227","DOIUrl":"https://doi.org/10.1197/JAMIA.M1227","url":null,"abstract":"Drawing software from Lassalle Technologies1 (France) designed for Visual Basic is the tool we used to standardize the creation, storage, and retrieval of flow diagrams containing information about adverse events and close calls.","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"144 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124885494","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and workload assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of “non-routine events” is introduced and pilot data are presented. The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.
{"title":"Human Factors Research in Anesthesia Patient Safety: Techniques to Elucidate Factors Affecting Clinical Task Performance and Decision Making","authors":"M. Weinger, J. Slagle","doi":"10.1197/JAMIA.M1229","DOIUrl":"https://doi.org/10.1197/JAMIA.M1229","url":null,"abstract":"Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and workload assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of “non-routine events” is introduced and pilot data are presented. The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128038818","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kathy A. Johnson, J. Svirbely, M. Sriram, Jack W. Smith, G. Kantor, J. R. Rodriguez
The National Patient Safety Foundation has sponsored a report to describe the current research being pursued in the area of medical error reduction and to identify the gaps in this effort.1 A total of 23 gaps were identified—among them was a need for more research in the area of communication and information sharing. One of the areas that we see a need to explore is the wealth of published information in the form of medical algorithms. Centralizing and automating medical algorithms is one way to share information among a wide range of clinical care providers. Furthermore, automation of medical algorithms assists in the correct selection (reducing errors of planning) and application of that information (reducing errors of execution). The …
{"title":"Poster Abstract: Automated Medical Algorithms: Issues for Medical Errors","authors":"Kathy A. Johnson, J. Svirbely, M. Sriram, Jack W. Smith, G. Kantor, J. R. Rodriguez","doi":"10.1197/JAMIA.M1228","DOIUrl":"https://doi.org/10.1197/JAMIA.M1228","url":null,"abstract":"The National Patient Safety Foundation has sponsored a report to describe the current research being pursued in the area of medical error reduction and to identify the gaps in this effort.1 A total of 23 gaps were identified—among them was a need for more research in the area of communication and information sharing. One of the areas that we see a need to explore is the wealth of published information in the form of medical algorithms. Centralizing and automating medical algorithms is one way to share information among a wide range of clinical care providers. Furthermore, automation of medical algorithms assists in the correct selection (reducing errors of planning) and application of that information (reducing errors of execution).\u0000\u0000The …","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"116 11","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"113999840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2002-07-01DOI: 10.1136/jamia.2002.0090409
W. Stead
Stephen Altschul is a Senior Investigator at the National Center for Biotechnology Information, which is part of the National Library of Medicine at the National Institutes of Health. He received his AB summa cum laude in mathematics from Harvard College and a PhD in mathematics from the Massachusetts Institute of Technology. Dr. Altschul held an IRTA postdoctoral fellowship at the Mathematics Research Branch of the National Institute of Diabetes and Digestive and Kidney Diseases before moving to the NCBI, where he has been for the past 12 years. His research has focused on developing measures, algorithms, and statistics for the comparison and analysis of DNA and protein sequences. He played a central role in developing the blast and psi-blast sequence database search programs, and his articles describing these programs have become, respectively, the most cited scientific papers published since 1990 and 1995. Dr. Altschul has served on grants committees for the National Human Genome Research Institute of the NIH and for the Medical Research Council of Canada. He has been a member of the editorial boards of Protein Sequences & Data Analysis, Gene-combis , and Genome Biology and is invited to be a keynote speaker at the Tenth Annual Conference on Intelligent Systems for Molecular Biology. Dennis Benson is Chief of the Information Resources Branch at the National Center for Biotechnology, National Library of Medicine. Dr. Benson received his undergraduate and graduate degrees in the neuroscience program at the University of Florida. Prior to his current position, Dr. Benson was a postdoctoral fellow in the Department of Biomedical Engineering, Johns Hopkins School of Medicine, where his research focused on the neurophysiology of the auditory cortex. He came to the Lister Hill Center for Biomedical Communications at the NLM in 1980 and worked on knowledge-based retrieval systems in the area …
Stephen Altschul是国家生物技术信息中心的高级研究员，该中心是美国国立卫生研究院国家医学图书馆的一部分。他以优异成绩获得哈佛大学数学学士学位，并获得麻省理工学院数学博士学位。Altschul在美国国家糖尿病、消化和肾脏疾病研究所数学研究部获得了IRTA博士后奖学金，之后他在NCBI工作了12年。他的研究主要集中在开发用于DNA和蛋白质序列比较和分析的测量、算法和统计。他在开发爆炸和psi爆炸序列数据库搜索程序方面发挥了核心作用，他的文章分别成为1990年和1995年以来发表的被引用最多的科学论文。Altschul曾在美国国立卫生研究院的国家人类基因组研究所和加拿大医学研究委员会的拨款委员会任职。他是《蛋白质序列与数据分析》、《基因组合》和《基因组生物学》编辑委员会的成员，并受邀在第十届分子生物学智能系统年会上作主题演讲。丹尼斯·本森是国家生物技术中心、国家医学图书馆信息资源分部的负责人。Benson博士在佛罗里达大学(University of Florida)获得神经科学专业的本科和研究生学位。在担任现职之前，Benson博士是Johns Hopkins School of Medicine生物医学工程系的博士后，他的研究重点是听觉皮层的神经生理学。1980年，他来到NLM的Lister Hill生物医学传播中心，在该领域从事基于知识的检索系统的研究。
{"title":"American College of Medical Informatics Fellows and International Associates, 2001","authors":"W. Stead","doi":"10.1136/jamia.2002.0090409","DOIUrl":"https://doi.org/10.1136/jamia.2002.0090409","url":null,"abstract":"Stephen Altschul is a Senior Investigator at the National Center for Biotechnology Information, which is part of the National Library of Medicine at the National Institutes of Health. He received his AB summa cum laude in mathematics from Harvard College and a PhD in mathematics from the Massachusetts Institute of Technology.\u0000\u0000\u0000\u0000Dr. Altschul held an IRTA postdoctoral fellowship at the Mathematics Research Branch of the National Institute of Diabetes and Digestive and Kidney Diseases before moving to the NCBI, where he has been for the past 12 years. His research has focused on developing measures, algorithms, and statistics for the comparison and analysis of DNA and protein sequences. He played a central role in developing the blast and psi-blast sequence database search programs, and his articles describing these programs have become, respectively, the most cited scientific papers published since 1990 and 1995.\u0000\u0000Dr. Altschul has served on grants committees for the National Human Genome Research Institute of the NIH and for the Medical Research Council of Canada. He has been a member of the editorial boards of Protein Sequences & Data Analysis, Gene-combis , and Genome Biology and is invited to be a keynote speaker at the Tenth Annual Conference on Intelligent Systems for Molecular Biology.\u0000\u0000Dennis Benson is Chief of the Information Resources Branch at the National Center for Biotechnology, National Library of Medicine. Dr. Benson received his undergraduate and graduate degrees in the neuroscience program at the University of Florida.\u0000\u0000Prior to his current position, Dr. Benson was a postdoctoral fellow in the Department of Biomedical Engineering, Johns Hopkins School of Medicine, where his research focused on the neurophysiology of the auditory cortex. He came to the Lister Hill Center for Biomedical Communications at the NLM in 1980 and worked on knowledge-based retrieval systems in the area …","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"50 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121431727","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dr. Patterson's letter was greatly appreciated and reinforces the major arguments in our paper: that not all order entry systems are created equal and that user satisfaction is important to the acceptance of order entry systems and must be assessed after system implementation.1 Mount Sinai's decision to purchase and implement a computerized physician order entry (CPOE) system was …
{"title":"Drs. Murff and Kannry reply","authors":"H. Murff, J. Kannry","doi":"10.1197/JAMIA.M1057","DOIUrl":"https://doi.org/10.1197/JAMIA.M1057","url":null,"abstract":"Dr. Patterson's letter was greatly appreciated and reinforces the major arguments in our paper: that not all order entry systems are created equal and that user satisfaction is important to the acceptance of order entry systems and must be assessed after system implementation.1\u0000\u0000Mount Sinai's decision to purchase and implement a computerized physician order entry (CPOE) system was …","PeriodicalId":344533,"journal":{"name":"J. Am. Medical Informatics Assoc.","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2002-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126792786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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