ISMP

Multiple Latent Failures Align to Allow a Serious Drug Interaction to Harm a Patient

By the Institute for Safe Medication Practices

Whenever ISMP assists hospitals with a root cause analysis or conducts its own investigation of an adverse event, we inevitably uncover numerous precipitating latent failures (see definition in box at the end of the article) that led to the actual event. Similar to dominos that require perfect alignment in order to collapse in a series, latent failures also must align perfectly for an event to occur and go unnoticed.

Surveillance Technology

Taking CDS to the Next Level for Medication Management

By Steve Riddle, BSPharm, BCPS, FASHP

Consider the following scenario. A patient in a hospital acquires pneumonia. When the attending physician enters an order for the antibiotic ceftriaxone, an alert pops up indicating that the patient is allergic to the medication. Based on the information provided, the physician chooses another appropriate medication. In this case, clinical decision support (CDS) did its job.

Trends

A Closer Look at FDA’s Adverse Event Reporting System

By Brian Overstreet

The U.S. Food and Drug Administration (FDA) is responsible for safeguarding patients and protecting public health by assuring the safety, efficacy, and security of medications. In order to accomplish this, the FDA’s primary monitoring process in preventing adverse drug events that occur with marketed drugs is the Adverse Event Reporting System (AERS), a computerized information database.

Editor’s Notebook

Technology and Culture

By Susan Carr

Each year, the January/February issue of PSQH is distributed at the HIMSS conference and exhibition, the largest annual event focused on health information technology, which takes place this year Feb. 20 to 24 in Las Vegas. Accordingly, this issue  has a higher than average percentage of articles about technology and information systems, including electronic medical records, device integration, “big data,” business intelligence software, and adverse event reporting systems.

Health & IT Quality

Big Data Drives Big Change

By Barry P. Chaiken, MD, FHIMSS

Every MBTA bus in Boston carries a networked sensor that broadcasts the location of the bus along its route. This allows smartphone users to know exactly when the next bus will arrive at their corner stop, and MBTA supervisors to monitor the performance of drivers.

Every new General Motors automobile includes an event data recorder (EDR) that captures information about the car’s performance during an accident. Law enforcement and insurance companies use this information to help determine the cause of accidents, while car manufactures utilize the information to assist them in designing safer cars.

Device Integration

EMR Adoption and the Roles of the CMIO and CNO

By Susan Niemeier, RN, BSN, MHA

U.S. hospitals have been focused on achieving criteria outlined in meaningful use since the passage of the American Recovery and Reinvestment Act (ARRA).  According to the 22nd Annual HIMSS Leadership Survey, half of respondents identified meeting meaningful use criteria as their organization’s top IT priority, and two-thirds of respondents reported that their organization has already made additional IT investments to position themselves to qualify for the incentives associated with achieving meaningful use.