Safety of Health IT : Clinical Case Studies.

Intro -- Dedication -- Acknowledgements -- Contents -- Contributors -- Chapter 1: First Do No Harm: An Overview of HIT and Patient Safety -- Introduction -- Unintended Consequences and Safety Risks of Health Information Technology -- The Sociotechnical Context of Health Information Technology -- Why This Book? -- The Road Ahead -- References -- Chapter 2: An Overview of HIT-Related Errors -- Introduction -- HIT Generates Errors That Can Harm Patients -- Evidence About Patient Harms Associated with HIT Is Mounting -- HIT Errors Are Linked to System Design, Implementation and Use -- Classification of HIT Errors -- Conclusion -- References -- Part I: Errors Related to Various Types of Health Information Technologies -- Chapter 3: Errors Related to CPOE -- Introduction -- Case Study -- Clinical Summary -- Analysis -- Solutions -- Consumers -- Vendors and Institutional Developers -- Discussion -- Key Lessons Learned -- References -- Chapter 4: Errors Related to Alert Fatigue -- Introduction -- Case Study 1: International Normalized Ratio (INR) Overshoot -- Clinical Summary -- Analysis -- What Happened? -- Why Did It Happen? -- Lack of Knowledge -- Severity Unclear from Alert Text -- Severity Rating Similar -- Severity Unclear from Alert Pop-Up -- Too Many Alerts -- Overriding Default Option -- Different Specialties -- Summary of Causes -- Solutions -- Case Study 2: An Overdose of Paracetamol -- Clinical Summary -- Background Information -- Analysis -- What Happened? -- Why Did It Happen? -- Lack of Knowledge -- Alert Pop-Up Too Complicated -- Too Many Alerts -- Trust in Checks by Other People -- Default is "Adjusting the Order" -- Summary of Causes -- Solutions -- Discussion -- Key Lessons Learned -- References -- Chapter 5: Errors Related to Bar Code-Assisted Medication Administration -- Introduction -- Clinical Case Studies -- Case 1.

Clinical Summary -- Analysis -- Solutions -- Case 2 -- Clinical Summary -- Analysis -- Solutions -- Case 3 -- Clinical Summary -- Analysis -- Solutions -- Discussion -- Key Lessons Learned -- References -- Chapter 6: Errors Related to Outpatient E-Prescribing -- Introduction -- Case Studies -- Case Study 1: Retrieving Incorrect E-Prescriptions -- Clinical Summary -- Analysis -- Communication Lapses -- Insufficient Doctor-Patient Communication -- Inadequate Clinic-Pharmacy Communication -- Training on E-Prescribing Capabilities -- Solutions -- Case Study 2: Incorrect Drug Quantity Detected in Community Pharmacy -- Clinical Summary -- Analysis -- Detection of Medication Errors in E-Prescribing -- E-Prescription System Design -- Provider Interaction with E-Prescribing Systems -- Solutions -- Summary -- Key Lessons Learned -- References -- Chapter 7: Errors Related to Alarms and Monitors -- Background -- Alarm-Related Harm Data -- Contributing Factors to Alarm-Related Patient Harm -- Alarm Hazards and Potential Failures -- Alarm Activation -- Alarm Load -- Alarm Notification Process -- Alarm Content -- Alarm Escalation/Backup -- Policies, Practice, and Education -- Case Study 1: Middleware Failure -- Steps in FMEA -- Map the Process -- Hazard Analysis -- Action Plan -- Case Summary -- Case Study 2: ECG Bedside Monitoring Signal Disruption -- Observation Unit Signal Loss -- Identifying the Issue -- Investigation -- Data Collection -- Analysis and Action -- Case Summary of ECG Signal Failure -- Key Lessons -- References -- Chapter 8: Errors Related to Personal Mobile Technology -- Introduction -- Infection Control Risks -- Emerging Risk: Privacy -- Clinical Summary of Case Study 1 About Privacy Risks -- Case 1 -- Analysis -- Solutions -- Increase Knowledge Around Privacy Requirements -- Design Technology to Support Clinical Communication Needs.

Consultant with Clearer Limits on Span of Responsibility and Practice Location -- Major Risk: Interruption and Distraction -- Clinical Summary of Case Study 2 Regarding Distraction Risk -- Case 2 -- Analysis -- A Variation on Case Study 2 About Distraction Risks -- Solutions -- Technical -- Education -- An Example of Cognitive Limitations -- Conclusion and Key Lessons Learned -- Key Lessons -- References -- Part II: Health Information Technology Implementation Issues -- Chapter 9: Improving Clinical Documentation Integrity -- Introduction -- Clinical Case Studies -- Case Study 1: Copy-Paste -- Case Study 2: Inadequate Discharge Summary -- Discussion/Analysis -- Latent Conditions -- Execution Errors -- Planning Errors -- Corrective Actions/Risk Mitigation Strategies -- Addressing Latent Conditions -- Addressing Execution Failures -- Addressing Planning Failures -- A Different Solution -- Key Lessons -- References -- Chapter 10: EHR and Physician-Patient Communication -- Introduction -- EHRs and the Rise of the "iPatient" -- Exam Room Computing Through the Lens of Human Factors -- Situation Awareness -- Interaction Complexity -- Ergonomics -- EHRs and Communication -- Recommendations -- Conclusion -- References -- Chapter 11: Patient Identification Errors and HIT: Friend or Foe? -- Introduction -- Case Studies -- A. Orders Placed on the Wrong Patient -- Results of the Patient Picture and Order Verification Process -- B. Documentation in the Wrong Patient's Chart -- C. Bedside Errors in Medication Administration -- Conclusion -- References -- Chapter 12: Errors Related to Health Information Exchange -- Introduction -- Errors Related to Patient Identification and Matching -- Case Study -- Clinical Summary -- Analysis -- Solutions -- Errors Related to Efforts to Protect Patient Privacy -- Case Study -- Clinical Summary 1 -- Clinical Summary 2 -- Analysis.

Solutions -- Key Lessons Learned -- Policy Efforts to Avoid Patient Safety Failures from HIE -- Provider Organization Efforts to Avoid Patient Safety Failures from HIE -- References -- Part III: Specialty Considerations -- Chapter 13: Safety Considerations in Radiation Therapy -- Introduction -- Case Studies -- Clinical Case #1 -- Clinical Summary -- Analysis -- Solutions and Lessons Learned -- Clinical Case #2 -- Analysis -- Solutions -- Key Lessons Learned -- References -- Chapter 14: Safety Considerations in Pediatric Informatics -- Introduction -- Case Study 1 -- Clinical Summary -- Analysis -- Solutions -- Case Study 2 -- Clinical Summary -- Analysis -- Solutions -- Case Study 3 -- Clinical Summary -- Analysis -- Solutions -- Miscellaneous Factors Affecting Safety of HIT in Pediatrics -- Key Lessons Learned -- References -- Chapter 15: Safety Considerations in Ambulatory Care Informatics -- Introduction -- Case 1: Temporal Ambiguity Leading to Inaccurate Plans for Preventive Care -- Clinical Summary -- Case Analysis -- Proposed Solutions -- Case 2: Terminology Idiosyncrasies Leading to Population Management Failure -- Clinical Summary -- Case Analysis -- Proposed Solutions -- Conclusion -- References -- Part IV: Organizational Considerations -- Chapter 16: HIT and Medical Liability Risks -- Introduction -- Clinical Case Studies -- Case Study 1: Clinical Summary -- Analysis -- Solutions -- Case Study 2: Clinical Summary -- Analysis -- Solutions -- Key Lessons Learned -- References -- Chapter 17: Improving HIT Safety Through Enterprise Risk Management -- Introduction -- Technology-Induced Errors: A Concern for Health Care Organizations -- Understanding the Origins and Contributing Factors to Technology-Induced Errors -- Managing the Risk of Technology-Induced Errors -- Clinical Simulations -- Case Study -- Clinical Summary -- Analysis -- Solutions.

Key Lessons Learned -- References -- Chapter 18: Managing HIT Contract Process for Patient Safety -- Introduction -- Key HIT Contract Provisions that Impact Patient Safety -- "Entire Agreement" Clause Excludes Anything Not in the Agreement -- Disclaimer of Warranties -- Term of Support and Transition Services After Termination -- Understanding Backup and Possible Exclusion of Damages for "Lost Data" -- Indemnification -- Confidentiality and Non-disclosure Agreements (NDAs) -- Conclusion -- References -- Chapter 19: Improving Safety of Medical Device Use Through Training -- Introduction -- Case Studies -- Smart Infusion Pump -- PCA Pump -- Physiological Monitor -- Solutions -- Select Wisely -- Develop Training to Supplement That Provided by the Vendor -- Determine What Needs to Be Trained -- Standardize Training -- Obtain Assistance from External Resources -- Embedded Training -- Assess Competency -- Discussion -- Vendor Supplied Training -- New Forms of Training Delivery -- Key Lessons Learned -- References -- Index.

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Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2024. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries.