# data[].attributes.body
Introductory video👩🏻‍⚕️

# data[].attributes.body
When we create a culture where the safety of the people we are in charge of caring for is the utmost importance, we have created a culture of safety.

# data[].attributes.body
"A 'culture of safety' describes the core values and behaviors that come about when there is a collective and continuous commitment by organizational leadership, managers, and health care workers to emphasize safety over competing goals."

# data[].attributes.body
1. Assess your hospital's current safety culture performance.

2. Analyze data to make targeted improvements.

3. Start with a unit-based safety culture improvement approach.

4. Make error reporting transparent, and use adverse events as opportunities for improvement instead of punishment.

# data[].attributes.body
Continuing education, hospital management support, supervisor/manager expectations, communication about errors, and teamwork are all found to be major patient safety culture predictors. Investing in practices and systems that focus on improving these aspects is likely to enhance the culture of patient safety in hospitals.

Strategies to nurture patient safety culture in hospitals should focus upon building leadership capacity that support open communication, blame-free culture, team work, and continuous organizational learning.

Through more frequent in-service trainings, patient safety awareness should be raised and nurse training should be kept up-to-date. (Lippincott, 2017)

# data[].attributes.body
Smart Pumps

# data[].attributes.attachment_link.title
Reducing Medication Errors with Smart Pumps

# data[].attributes.headline
Strategies for developing a safety culture by the Joint Commission

# data[].attributes.subject
Strategies for developing a safety culture by the Joint Commission

# data[].attributes.headline
When you find out today's safety briefing is about something you did...

# data[].attributes.subject
When you find out today's safety briefing is about something you did...

# data[].attributes.attachment_link.readable_text
By Tim Vanderveen, PharmD, MS

All infusion pumps will be connected to a hospital wireless network.

All infusion pumps will be associated with a specific patient and clinician.

Image recognition (barcode, radio frequency identification) will be used to identify the IV drug/concentration being infused.

Infusion pumps will be automatically programmed from the pharmacist-reviewed physician's order.

Smart pump safety software will protect against programming errors during titrations, bolus dosing, STAT infusions, and in OR/procedure areas.

All IV infusion data will be automatically recorded in each patient's electronic medical record in near real-time.

Infusion status of all infusions will be available to pharmacy to facilitate IV compounding.

Discrepancies between in-process infusions and computerized prescriber-order-entry orders will be identified for resolution.

Critical lab values and missing lab values that impact IV infusions will be immediately communicated to the appropriate caregiver.

All patients receiving high-alert IV medications will be continuously monitored with appropriate vital sign monitoring, even outside the ICU.

Infusion pump alarms and alerts will be sent directly to the appropriate caregiver(s).

Infusion pump performance issues will be automatically communicated to the biomedical staff.

A little more than a decade ago the introduction of "smart" pumps with dose error-reduction systems (DERS) dramatically improved the safety of intravenous (IV) infusion therapy. Wireless connectivity enhanced system management and laid the foundation for integrating smart pumps with other systems and devices. Now, being able to integrate what previously have been isolated "islands" of individual infusion pumps with other systems opens the door to interoperability and further dramatic improvements in infusion safety, nursing and pharmacy productivity, clinical decision-making, patient monitoring, alarm notification, and reduction in variation and waste.

Interoperability is a journey and not a destination. Hospitals can start anywhere in the spectrum of opportunities that will be coming along, based on need and HIT capabilities. However a hospital chooses to begin, an ultimate goal is to connect and monitor all infusion-related systems with surveillance patterned after the air traffic control systems. In much the same way as the air traffic controller works with pilots to help planes fly more safely, one can envision a future IV medication system that is fully integrated with other systems and would automatically flag any critical, infusion-related situation that requires immediate attention, adding a new dimension to IV infusion safety.

The information in this article is drawn from more than four decades' academic and industry involvement with improving IV infusion safety and includes descriptions of major accomplishments to date, examples of the changes happening right now, and a future vision for further advances (sidebar), some of which are already in use in early-adopter hospitals.

From "Dumb" to "Smart" Pumps

The first programmable IV infusion pumps came into use more than 40 years ago. Being able to program a specific rate and volume made modern infusion therapy possible; but these "dumb" pumps could accept any infusion rate from 0.1 to 999 mL/hr or higher. Programming 54 instead of 5.4, 800 instead of 8, or entering the volume as the rate could each deliver a fatal dose. Compared to medications delivered via other routes, IV medication errors are twice as likely to cause patient harm (Proceedings, 2008). For the next three decades, the potential for pump mis-programming and other errors remained a critical issue.

In the late 1990s a technological breakthrough-electronically erasable programmable read-only memory (EEPROM)-made it possible to develop "smart" pumps with safety software that could be customized to a hospital's specific care areas and patient types. The customized software generated an alert or prevented infusion altogether if pump programming exceeded the hospital-established limits. The widespread implementation of such pumps significantly improved IV medication safety. In more than 10 years since their introduction, smart pumps have:

Fostered development of drug dose limits.

Promoted standardization of concentration and dosing units.

Allowed hospitals to configure pumps to match applications.

Provided a "treasure trove" of infusion data.

Documented many "good catches" of prevented programming errors.

Uncovered high degree of variation in infusion practices.

Identified human factors issues/opportunities for manufacturers.

Promoted wireless connectivity/server applications.

Figure 1. Infusion Auto-Pump Programming Using Barcode Scanning
The most significant advance in smart pump use came in 2003 with the introduction of wireless connectivity. The implementation of bidirectional wireless connectivity between hundreds of pumps and a single server allowed hospitals to upload software revisions and download infusion data much more easily. This greatly enhanced infusion safety and continuous quality improvement (CQI) efforts. A 2005 study of 426 IV infusions prior to smart pump implementation showed that 67% had one or more discrepancies and errors, including wrong infusion rates and doses, infusions without orders, and infusions continuing after discontinuation orders (Husch et al., 2005). For errors associated with pump programming, only one potentially would have been identified by DERS. A 2010 study evaluating almost 600 in-process infusions showed that 24% of drug infusions and 42% of fluid infusions had a "mismatch" between computerized prescriber order entry (CPOE) orders and smart pump programming (Russell et al., 2010). Available pumps have limitations such as the following:

Typically not assigned to specific patients.

Not aware of intended therapy.

Cannot prevent drug mix-ups, incorrect library selection.

Do not record caregiver or reason for alert overrides.

Do not populate infusion records.

Do not maximize value of BCMA.

Do not overcome poor compliance with DERS use or rapid overrides of alerts.

Do not communicate alarms, alerts, or status of infusions in near-real time.

Smart pumps are still not "smart" enough to ensure the "Five Rights" of right drug, dose, route, patient, and time, much less right response and documentation. Barcode medication administration (BCMA) can help ensure these rights and works very well for tablets, unit-dose liquids, and injections for which the drug administration is a discrete "event." Scanning the nurse, patient, and medication and administering the drug completes the event. However, many IV infusions are a continuing "process" involving initial programming and often subsequent changes with multiple nurses involved in the therapy. While smart pumps and BCMA coexist in many hospitals, except in a very small number they are not integrated. Addressing the complexity of IV therapy requires an integrated approach (Husch et al., 2005).

From "Smart" Pumps to "Intelligent" Systems

A major limitation has been that even with connectivity, infusion pumps typically operate in insolation-not assigned to a particular patient, not aware of the intent of therapy, unaware of caregiver proximity, and unable to interact with other safety technologies. Wireless connectivity and direct communication with BCMA, the hospital information system (HIS), and other systems can overcome these shortcomings and elevate the current smart pumps to the new level of "intelligent" infusion system (Figure 1, pg. 24). Fully developing and implementing such systems will take time, but the impact will be dramatic.

Consider that infusion pump auto-programming and auto-documentation first went live December 2003 at Pittsburgh's Ohio Valley General Hospital. Barcode scanning the IV container label triggered the transfer of programming information from the BCMA system to the pump. Infusion data were automatically sent from the pump to the electronic medication administration record (eMAR). From December 2003 to April 2004, medication errors that needed to be averted declined by 12% (Obsheatz, 2004). However, clinical scope, technologies, analytics, and expertise required further development before widespread implementation would be possible.

The 2011 American Society of Health-System Pharmacists National Survey showed that in the intervening eight years, the vast majority of hospitals had implemented or budgeted for the foundational technologies of CPOE, BCMA, smart pumps, and electronic medical records (EMRs) (Pedersen et al., 2012). Almost a decade after Ohio Valley General Hospital's implementation, the technologies, software applications, regulatory approvals, and multidisciplinary teams were in place in most large hospitals to implement scalable, sustainable, reliable smart pump-EMR integration for house-wide clinical use.

Figure 2. Fully Integrated, Closed-Loop, Medication Safety System
©2013 CareFusion

Possible Starting Points

Several factors make infusion pumps an ideal starting point for interoperability: the very large number of devices in a typical hospital, the critical importance of the drugs being infused, the growing base of wirelessly connected pumps already installed, and their uniquely bidirectional information transfer, both from and to the pump. A few hospitals have already implemented closed-loop systems that integrate BCMA, smart pumps, and the electronic medical record (EMR), as described below. But other entry points are also possible. For example, one hospital might decide that interfacing the smart pump and BCMA systems is the highest priority, while another might choose to work on sending alarms directly to the patient's clinician. An ultimate goal is to connect and monitor all infusion-related systems in a type of "air traffic control" surveillance that would automatically flag any critical, infusion-related situation that requires immediate attention.

Associating Pumps and Patients

A fundamental requirement for infusion pump interoperability is the ability to associate the pump and the patient. Without this association, the vision cannot be realized, and infusion pumps, despite wireless connectivity, will continue to be islands of information. This limits their ability to be integrated with data from other systems.

The good news on that front is that today some infusion pumps can be associated with specific patients in a variety of ways, including manual entry of the patient ID using the pump key pad, using a barcode scanner integrated into the infusion pump to scan the barcode on the patient's wristband or IV container label, or using a recently introduced patient-pump association application on the BCMA scanner, whether handheld or on a computer on wheels. An immediate benefit of this patient/pump association is that the CQI data from the smart pump DERS logs now can be put into the patient context, which makes it possible to retrospectively analyze specific DERS events such as a high-risk override or incorrectly programmed infusion. The longer-term benefits will be discussed later, as patient/pump association is an enabler for all future interoperability.

Auto-Pump Programming and Auto-Documentation

Two capabilities have been at the top of nurses' integration wish list: the ability to automatically send the physician's order to pre-program the infusion parameters directly into the pump, and the ability to automatically record the initial programming and all subsequent changes in the EMR, so the clinician only has to confirm the pump programming and infusion record. After many years of development and clinical testing, these capabilities now have been implemented for regular clinical use (Vanderveen, 2013). Integrating smart pumps not only with the BCMA system but also with the EMR creates a closed-loop, fully integrated medication safety system for both large-volume and syringe IV infusion pumps that accomplishes both auto-pre-programming and auto-documentation (Figure 2) (Vanderveen, 2013).

In this system, a physician orders a medication into the EMR using CPOE. A pharmacist then verifies the order to ensure appropriateness and sends it to the patient's EMR. Prior to administration, a nurse scans the patient's armband and the drug label to verify the right patient, medication, time, dose, and route against the order in the EMR. For infusions, one additional scan-that of a barcode on the smart pump-triggers wireless transmission of the ordered infusion parameters from the EMR to preprogram the pump. The nurse verifies the information on the smart pump, accepts the data, and the infusion begins. Throughout infusion, the DERS software in the pump acts as an additional safety feature that continues to protect against errors in manual programming of titrations, bolus doses, STAT infusions, and also infusions for which there would be no physician's order, such as in anesthesia and procedural sedation. For the initial programming and all subsequent changes, the rate, dose, infused volume of medication, and other data are wirelessly sent back to the patient's EMR from the smart pump for the nurse to review and accept into the EMR (Vanderveen, 2013). Nurses must confirm the correct documentation, but manual records are eliminated.

Auto-documentation provides substantial productivity gains for nurses. Especially with critically ill patients on multiple pumps, documenting their multiple infusions requires a considerable amount of time, is often delayed, and may introduce critical errors. Automatically documenting the infusion history via the wireless transfer of each patient's infusion pump data to the EMR allows the nurse to concentrate more on patient care. Physicians, pharmacists, nurses, respiratory therapists, and other staff members benefit from having clear, accurate, and timely documentation to use in managing each patient's therapy.

Patient Monitoring

Many IV infusion medications are high-alert drugs with a narrow therapeutic index. Careful monitoring is required to help ensure that a given dose is therapeutic and not toxic. Today there are only two examples of systems that fully integrate an infusion pump with patient monitors: one for administering and monitoring minimal-to-moderate sedation and a second for administering and monitoring patients receiving patient controlled analgesia (PCA). For example, the patient response to opioids delivered via PCA is highly variable, and patients at high risk of opioid-induced respiratory depression are not easily identified. Typically, patients receiving PCA therapy are monitored by intermittent clinician assessment, but during the first 24 hours and at night, clinicians may not monitor a patient frequently enough and over-medication may go undetected. Integration of the PCA pump with pulse oximetry and capnography (Figure 3) with automatic PCA pump pause (with alarm), if oxygen level and/or respiratory rate drop to potentially dangerous levels, has added a much needed safety net for PCA patients typically cared for in medical/surgical units. In the future, interoperability may be used to connect separate devices and systems to perform similar monitoring of a patient's blood pressure, blood glucose, or other response to infusion.

Figure 3. PCA Pump Integrated with Pulse Oximetry and Capnography

Infusion Status Monitoring

In the early 1970s, responsibility for preparing IV infusion admixtures began to shift from the physicians and nurses to the hospital pharmacy. This shift has brought numerous advantages with regard to safety, sterility, accuracy, compatibility, and labeling, but without knowing the status of each patient's infusions, scheduling subsequent IV infusions remains problematic. Infusions may be prepared and not used, other infusions may not be ready on time, etc. Wireless connectivity can change this. Knowing which pumps are assigned to which patients and the status of each patient's infusions will allow pharmacy to improve workflow, productivity, costs, and nursing-pharmacy relations. The ongoing critical drug shortages, ever-increasing cost of medications, and impact of regulations on IV compounding practices are all reasons to improve communication between the bedside and the compounding pharmacy. Near-real time infusion status on a pharmacy dashboard can alert the pharmacy staff to infusions that have been discontinued, infusion rates that have changed, and infusions that were ordered but never started.

Pump Maintenance

Maintaining hundreds and, in some hospitals, more than 1,000 infusion pumps in good working order is a huge task. Although modern infusion pumps have maintenance logs, a biomedical department often receives a pump with only a label attached that indicates "broken." Adverse patient events are frequently attributed to pumps that were not removed from service despite having performance issues. An example is a battery that no longer holds a charge. Despite frequent "low battery" alarms and needing to be charged for long periods, the pump may remain in clinical use. If the battery suddenly dies during a transport or there is a power interruption and a critical infusion stops, the adverse effects on the patient could be severe. Additionally, some performance issues are invisible to the clinicians but may appear in the log during routine maintenance.

Similar to the pharmacy dashboard, an integrated dashboard in the biomedical department could display the operating parameters for each pump, identify issues, and provide a pump's location, so that pump issues can be identified and addressed in a timely manner, before an adverse event occurs. The direct link between each pump and the biomedical department would be similar to the automotive industry's use of in-vehicle diagnostics and communication systems.

Alarm Management

Publication of The Joint Commission's Sentinel Event Alert, Issue 50, "Medical Device Alarm Safety in Hospitals" (2013 April 8), and National Patient Safety Goal 06.01.01, "Improve the safety of clinical alarm systems" (2013), has focused hospitals' attention on ways to reduce alarms, make patient care areas quieter, and increase patient and family member satisfaction. In a typical hospital, hundreds of infusion pumps sound alarms and alerts 24 hours per day. Adding to the noise level are U.S. and international standards that must be met regarding alarm loudness. Most alarms require a bedside visit to silence the alarm and determine the cause. Outside of the ICU, however, many pump alarms are not critical and may not require immediate attention.

The combination of patient-pump association and knowing the patient location, drug or fluid being infused, type of alarm, and the clinician responsible for the patient are the ingredients needed to address this issue effectively. Alarm-management companies are developing systems to distribute pump alerts and alarms directly to the patient's caregiver, potentially in advance of the actual bedside alarm. For example, sending a message to the patient's nurse that an infusion container has 15 minutes before an "infusion complete" alarm sounds could eliminate the bedside alarm all together. Smart alarms and intelligent alarms systems are exciting opportunities for improving safety, increasing nursing productivity, and increasing patient and family member satisfaction.

Figure 4. U.S. Electronic Medical Record Adoption Model

"Air Traffic Control" Integrated Surveillance

It's important to bear in mind that interoperability is a journey, not a destination. Even with interoperability, a system doesn't necessarily flag things that need to be brought to someone's attention. The next huge step forward will be systems that can act as a type of "air traffic controller" that knows whom to contact and can send an alert and/or command directly to the appropriate "pilot," concentrating on 747s and 737s, not Piper Cubs.

In the future, once the pump is assigned to the patient, a complete list of all active orders will be easily accessed. The smart pump can send information on everything the pump is doing to the server. A pharmacist, nurse, or physician can instantly see if an infusion is on- or off-target, as the intelligent surveillance system automatically flags situations such as the following:

The infusion that is running is not what was ordered; for example, the order is for heparin 1000 Units/hr, but the pump is programmed for 100 Units/hr.

A nurse has overridden an alert, potentially leading to a serious adverse event.

A drug infusion has been ordered, but there is no evidence in the system that the drug is being infused.

An order has been discontinued, but the infusion continues.

A patient has been on an IV anticoagulant, but the required clotting studies have not been ordered.

The patient's potassium level is low, and the nurse should not administer the next dose.

In much the same way that alerts need to be managed to avoid fatigue and help staff to recognize the critical alerts, intelligent systems will need to provide enterprise-wide surveillance that automatically flags issues that require immediate attention and clinical decision support systems to help guide the appropriate response.

Making the Journey

For many hospitals, interoperability through integrated systems is still a long way off. But even with today's stand-alone devices, hospitals can do much to optimize use of their existing smart pumps and prepare for the implementation of integrated systems. For example, hospitals can:

Ensure that all smart pumps are on wireless networks to optimize smart pump drug library management.

Make sure that all available safety features are enabled.

Manage the drug libraries aggressively so they reflect best practice and are easy for nurses to use.

Make sure that important alerts are not masked by nuisance alerts.

Regularly analyze data on alerts and subsequent actions to provide actionable information that can be used to help improve therapy, medication safety, and clinical alarm management.

Track and report CQI and compliance data to help achieve high rates of compliance with use of smart pump safety features.

Take the necessary steps to advance from HIMSS's EMR Adoption Stages 1 to 5 (Figure 4), in order to prepare for more advanced integration.

The purpose of making this journey, of course, is not just to achieve ever-increasing technological integration and interoperability but to improve IV infusion safety, quality of care, clinician satisfaction, financial performance, and patients' well-being. Developing and holding the vision of interoperability that is best suited to one's own institution is a critical first step.
Tim Vanderveen is vice president of the CareFusion Center for Safety and Clinical Excellence in San Diego, California. He may be contacted at tim.vanderveen@carefusion.com.
References

Healthcare Information and Management Systems Society. US EMR Adoption Model(SM). Retrieved April 18, 2014 from http://www.himssanalytics.org/hc_providers/emr_adoption.asp

Husch, M., Sullivan, C., Rooney, D., Barnard, C., Fotis, M., Clarke, J., & Noskin, G. (2005). Insights from the sharp end of intravenous medication errors: Implications for infusion pump technology. Quality and Safety in Health Care, 14(2), 80-86. doi:10.1136/qshc.2004.011957

The Joint Commission. (2013, April 8). Medical device alarm safety in hospitals. Sentinel Event Alert, 50. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF

The Joint Commission. (2013). National Patient Safety Goals Effective January 1, 2014. Hospital accreditation program. Retrieved from http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf

Obsheatz, M. (2004). Integrating bar code medication administration and intravenous medication safety systems. In: P. J. Schneider (Ed.). Measuring medication safety with smart IV systems. HealthLeaders, 7(12suppl), 51-55.

Pedersen, C. A., Schneider, P. J., & Scheckelhoff, D. J. (2012). ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration-2011. American Journal of Health-System Pharmacists, 69(9), 768-785.

Proceedings of a summit on preventing patient harm and death from IV medication errors. (2008). American Journal of Health System Pharmacists, 65, 2367-2379.

Russell, R. A., Murkowski, K., & Scanlon, M.C. (2010). Discrepancies between medication orders and infusion pump programming in a paediatric intensive care unit. Quality and Safety in Health Care, 19(Suppl3), i31-5. doi:10.1136/qshc.2009.036384

Vanderveen, T. (2013). Intravenous infusion medication safety: The vision becomes reality. Patient Safety & Quality Healthcare, 10(2), 24-30. Retrieved from http://www.psqh.com/marchapril-2013/1598-intravenous-infusion-medication-safety-the-vision-becomes-reality.html fu sing Patients Safely: A Future Vision

# data[].attributes.attachment_link.title
From Smart Pumps to Intelligent Infusion Systems - The Promise of Interoperability - Patient Safety & Quality Healthcare

# data[].attributes.attachment_link.description
A little more than a decade ago the introduction of "smart" pumps with dose error-reduction systems (DERS) dramatically improved the safety of intravenous (IV) infusion therapy. Wireless connectivity enhanced system management and laid the foundation for integrating smart pumps with other systems and devices.

# data[].attributes.headline
Using information technology to reduce rates of medication errors in hospitals

# data[].attributes.subject
Using information technology to reduce rates of medication errors in hospitals

# data[].attributes.attachment_link.readable_text
Division of General Medicine and Primary Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA

Data continue to show that medication errors are frequent and that adverse drug events, or injuries due to drugs, occur more often than necessary.1 ⁻4 In fact, the frequency and consequences of iatrogenic injuries seems to dwarf the frequency of other types of injuries that have received more public attention, such as aeroplane and automobile crashes.2 A recent meta-analysis reported an overall incidence of 6.7% for serious adverse drug reactions (a term that excludes events associated with errors) in hospitals.4 Between 28% and 56% of adverse drug events are preventable. 3 5 ⁻ 7

Though the reasons this issue has received so little attention are complex, the reasons that medical injuries occur with some frequency are perhaps less so; medicine is more or less a cottage industry, with little standardisation and relatively few safeguards in comparison to, say, manufacturing. In fact, most of the systems in place in medicine were never formally designed, and this holds for the entire process of giving drugs.

Take, for example, the allergy detection process used in our hospital several years ago, which was similar to that used in most hospitals at the time. Physicians, medical students, and nurses all asked patients what their allergies were. This information was recorded at several sites in ...

# data[].attributes.attachment_link.title
Using information technology to reduce rates of medication errors in hospitals

# data[].attributes.attachment_link.description
Data continue to show that medication errors are frequent and that adverse drug events, or injuries due to drugs, occur more often than necessary.1-4 In fact, the frequency and consequences of iatrogenic injuries seems to dwarf the frequency of other types of injuries that have received more public attention, such as aeroplane and automobile crashes.2 A recent meta-analysis reported an overall incidence of 6.7% for serious adverse drug reactions (a term that excludes events associated with errors) in hospitals.4 Between 28% and 56% of adverse drug events are preventable.

# data[].attributes.headline
The impact of health information technology on patient safety

# data[].attributes.subject
The impact of health information technology on patient safety

# data[].attributes.attachment_link.readable_text
Patient safety is a subset of healthcare and is defined as the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care. 1 In 1999 the Institute of Medicine's (IOM) report "To err is human" called for developing and testing new technologies to reduce medical error, 2 and the subsequent 2001 report "crossing the quality chiasm" called for using information technology as a key first step in transforming and changing the healthcare environment to achieve better and safer care. 3

Healthcare information technology (HIT) has been defined as "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making". 4

Health information technology includes various technologies that span from simple charting, to more advanced decision support and integration with medical technology. Health information technology presents numerous opportunities for improving and transforming healthcare which includes; reducing human errors, improving clinical outcomes, facilitating care coordination, improving practice efficiencies, and tracking data over time. Since the original IOM report was published, there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety.

This review is intended to summarize the current available scientific evidence on the impact of different health information technologies on improving patient safety outcomes. This review might be useful for clinicians and healthcare policy makers when making evidence based decisions on procurement and implementation of such technology to improve patient safety. This review considered studies that were conducted in the healthcare settings both inpatient and community setting, with an intervention of any of the following; electronic physician's orders (CPOE), clinical decision support (CDS), E-prescribing, electronic sign-out and hand-off tools, bar code medication administration (BCMA), smart pumps, automated medication dispensing cabinets (ADC), electronic medication administration record (eMAR), patient data management systems (PDMS), retained surgical items detectors, patient electronic portals, telemedicine, electronic incident reporting, and electronic medical record (EMR). Our primary outcomes of interest were patient safety, medical errors, adverse events, medication errors, adverse drug events, and mortality. The priority was given to systematic reviews, meta-analysis and randomized clinical trials. If such studies were not identified then other types of experimental studies or epidemiological study designs including; non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies and case control studies.

Studies were excluded if they met any of the following criteria: high risk of bias, studies that were conducted in non-clinical settings, cointerventions with non-health information technology interventions, not evaluating patient safety outcomes, qualitative or narrative studies.

The search strategy was conducted to find both published and unpublished studies. The search strategy included Medline, Embase, Cochrane Database. Studies published until January 2017 were considered for inclusion in this review. Initial keywords used were: Electronic Medical Record (EMR), Electronic Physician's Order entry (CPOE), Clinical Decision Support (CDS), E-prescribing, Electronic Sign-out and Hand-off, Bar Code Medication Administration (BCMA), Closed Loop Medication Administration, Patient Data Management Systems (PDMS), Retained Surgical Items Detectors, Patient Electronic Portals, Telemedicine, Electronic Incident Reporting, Intelligent Infusion Devices, Smart Pump, Programmable Pump, Automated Medication Dispensing, medication error adverse events, adverse drug events, adverse drug reactions, patient safety, medical errors. Studies were assessed for methodological validity and risk of bias using the Cochrane methodology prior to inclusion in the review.

Electronic physician's orders and E-prescribing

Computerized physician order entry entails the use of electronic or computer support to enter physician orders including medication orders using a computer or mobile device platform. 5 Computerized physician order entry systems were originally developed to improve the safety of medication orders, but more modern systems allow electronic ordering of tests, procedures, and consultations as well. Computerized physician order entry systems are usually integrated with a clinical decision support system (CDS), which acts as an error prevention tool through guiding the prescriber on the preferred drug doses, route, and frequency of administration. In addition, some CPOE systems may have the feature of prompting the prescriber to any patient allergies, drug-drug or drug-lab interactions or with sophisticated systems it might prompt the prescriber towards interventions that should be prescribed based on clinical guideline recommendation (example venous thromboembolism prophylaxis). A metaanalysis 6 evaluating the effectiveness of CPOE to reduce medication errors and adverse drug events in hospitals found that the implementation of a COPE with clinical decision support resulted in significant reduction in medication errors (RR:0.46; 95% CI 0.31 to 0.71) and adverse drug reactions (RR: 0.47; 95% CI 0.35 to 0.60). Similarly, studies conducted in community based outpatient services showed comparable results in reducing medication errors. 7, 8 The use of hard-stops as a measure of forcing function and error prevention in CPOE systems has been studied and was found to be effective in changing prescribing errors. However, the use of hard-stops resulted in clinically important treatment delays. 9

The use of a stand-alone CPOE without CDS does not seem to reduce medication errors. Studies that have evaluated the use of a basic CPOE system without a clinical decision support system showed that it did not improve overall patient safety or reduce medication errors. 10 Published research demonstrates that COPE systems are one of the most rigorously evaluated health information technologies, with a high level of scientific evidence regarding the reduction of medication errors, but this benefit is only consistent when used in combination with a CDS system.

Clinical decision support

Clinical decision support provides the health care professional with information and patient-specific information. This information is intended to enhance the decision of the healthcare provider and is rationally filtered and presented to the healthcare professional at appropriate times. Clinical decision support includes a range of tools to enhance decision-making and the clinical workflow. These tools include notifications, alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, patient specific clinical summaries, documentation templates, investigation and diagnostic support, among other tools. 11 A Cochrane systematic review 12 concluded that the use of on screen reminders for physicians resulted in minor to modest improvements in process adherence, medication ordering, vaccination, laboratory ordering and clinical outcomes.

Physicians tend to frequently ignore alerts from clinical decision support systems. A study 13 evaluated 18,115 drug alerts in the Boston area and found that 33% of alerts were ignored by the ordering physician. Several clinical trials 14, 15 have studied the effect of different CDS system modifications to improve physician's compliance to alerts and have found that "tiering" and "automation of alerts" resulted in improved physician's compliance to CDS alerts. A meta-analysis studied reasons for why some CDS systems succeed and improve patient outcomes and why others do not, and concluded that CDS systems which provided simple advice were less likely to succeed, while the odds of success were greater for CDS systems that demanded the healthcare provider to justify the reason when over-riding CDS advise. The odds of success were also better for CDS systems that provided advice simultaneously to patients and practitioners. In addition, CDS systems that were evaluated by their developer rather than third party developers were more likely to be successful. 16 Published research demonstrates consistent high-quality evidence that CDS systems improve quality of care and patient safety but the results may vary with different system designs and implementation methods.

Electronic sign-out and hand-off tools

Sign-out or "hand-over" communication relates to the process of passing patient-specific information from one caregiver to another, from one team of caregivers to the next, or from caregivers to the patient and family for the purpose of ensuring patient care continuity and safety. 17 Breakdown in handover of patient information has been found to be one of the leading root causes of sentinel events in the United States. 18 Electronic sign-out applications are tools used as standalone or integrated with the electronic medical record to ensure a structured transfer of patient information during healthcare provider handoffs. Two systematic reviews 19, 20 evaluating outcomes of electronic tools supporting physician shift-to-shift handoffs concluded that most studies supported using an electronic tool with an improvement in the process of handover, fewer omissions of critical patient information and reduced handover time when using the electronic tool with few low-quality studies assessing patient outcome measures. The authors in both reviews also noted that a significant number of the included studies were not well designed and further evaluation using rigorous study designs is needed.

Bar code medication administration

Bar code medication administration systems are electronic systems that integrate electronic medication administration records with bar code technology. These systems are intended to prevent medication error by ensuring that the right patient receives the right medication at the right time. Furthermore, there are varying levels of sophistication among existing barcode systems. For example, some software produces alerts when sound-alike or look-alike medications may be confused. Others provide clinical advisories for specific medications when scanned, and others may assist with documentation (namely, recording drug administration in the eMAR and other relevant clinical details). 21

Our literature search did not find any randomized controlled clinical trials on the use of barcode medication administration or closed loop medication administration. The highest level of clinical evidence on this technology is based on observational or quasi-experimental studies. A systematic review of quasi-experimental studies 22 found that bar code medication administration when integrated with electronic medication administration records may reduce medication administration errors by 50% to 80%. However, the systematic review did not elaborate on whether the included studies were evaluated for the quality of their methodology. The review also noted that there is a limited data on the use of barcode technology on pediatric and outpatient setting as most studies have been conducted in an inpatient adult setting. Another systematic review 21 conducted a meta-analysis of studies involving BCMA which found that implementing BCMA resulted in an overall reduction in medication errors by 57% (OR=0.425, 95% CI: 0.28-0.65, p<0.001). However, this result should be interpreted with caution as studies involved in the meta-analysis had a high degree of heterogeneity. Although BCMA automates and improves documentation of medication administration, there is a moderate to weak clinical evidence on its efficacy in reducing medication errors. Further robust studies are needed to make a conclusion. Healthcare organizations also need to consider the impact of implementing BCMA on their workflows.

Smart pumps

Smart pumps are intravenous infusion pumps that are equipped with medication error-prevention software. This software alerts the operator when the infusion setting is set outside of pre-configured safety limits. 23 The only published randomized controlled trial 24 on the impact of smart pumps on medication safety has shown that there was no statistical difference between activating the decision support feature on or off the smart pump. The authors had explained that this was likely in part due to poor compliance of healthcare providers to infusion practices. A systematic review of quasi-experimental studies 25 concluded that smart pumps may reduce programing errors but they do not eliminate such errors. The review also found that hard limits were more effective than soft limits in preventing medication errors. This was explained by the high override rate of soft limits. Further robust studies are needed to make a conclusion of the efficacy of smart pumps on reducing medication errors and improving patient's safety.

Automated medication dispensing technology

Automated dispensing cabinets (ADC) are electronic drug cabinets that store medication at the point of care with controlled dispensing and tracking of medication distribution. Automated dispensing cabinets were fist used in hospitals in the 1980s, but have evolved over time to include more sophisticated software and digital interfaces to synthesize high-risk steps in the medication dispensing process. Automated medication dispensing cabinets have been successfully used as a medication inventory management tool that help in automating the medication dispensing process by minimizing the workload on the central pharmacy and keeping better track of medication dispensing and patient billing. The impact of ADC on patient's safety is limited, as there is only one published controlled trial, 26 which found that the use of ADC resulted in a 28% ( p<0.05) reduction in the rate of medication errors in a hospital critical care unit (RR: 0.7; NNT: 4). Detailed analysis revealed that most reduced errors were preparation errors. The automated dispensing system did not reduce errors causing harm. Automated dispensing cabinets seem to reduce medication preparation errors in critical care setting. Although the level of evidence is high, it is however only limited to critical care setting. Further controlled studies are needed to make a conclusion on the impact of ADC on medication safety in other settings.

Retained surgical items prevention technology

There are various technologies that are used to enhance the prevention of retained surgical items which include: bar coding and radiofrequency (RFID) tagging of surgical items. A systematic review 27 identified 3 studies that evaluated technologies preventing retained surgical items. One study was a randomized control trial on the use of barcode assisted sponge count technology which found that there was no difference between the intervention group and the control group, but the time to conduct the count was significantly longer in the intervention. Another study evaluated the RFID tagging of surgical items and found statistically insignificant results. Currently, there is insufficient clinical evidence to recommend for or against the use of such technology. The use of such technologies must not be considered as a stand-alone procedure and must be supplementary to manual counts due to many reasons which include cost, confusion with older non-tagged devices, and wand technique with RF and RFID systems. 28

Patient electronic portals

A patient portal is a secure online application that provides patients access to their personal health information and 2-way electronic communication with their care provider using a computer or a mobile device. 29 Numerous studies 30- 32 have shown that patient portals improve outcomes of preventive care and disease awareness and self-management. However, there is no evidence that they improve patient safety outcomes.

Telemedicine

Telemedicine is defined as the use of telecommunication technologies to facilitate patient to provider or provider to provider communication. Communication maybe synchronous with real-time 2-way video communication or asynchronous transmission of patient clinical information. In addition to communication, telemedicine may provide health information that is collected remotely from medical devices or personal mobile devices. This information may be used to monitor patients, track or change their behavior. 33

Synchronous telemedicine

Virtual visits are real-time 2-way audio/video communication between a healthcare provider and a patient. Numerous systematic reviews 34- 37 have studied the impact of virtual visits on patient outcomes in critical care, chronic disease care, and psychiatric care. All have showed that telemedicine is as effective as face to face care with regard to specific clinical outcomes but there is limited evidence regarding patient safety outcomes. An e-consultation is an electronic communication between the patient's primary care clinician and a specialist using a secure communication platform. This technology facilitates guidance from the specialist regarding the management of the patient without the need for referring the patient. There is limited evidence about the efficacy and safety of e-consults, but studies have shown that e-consults may reduce patient wait times for specialist appointments and opinions. 38, 39

Remote patient monitoring

Studies evaluating community based Remote patient monitoring (telemonitoring) 40- 44 have shown that it improves patient outcomes for certain chronic conditions including; heart failure, stroke, COPD, asthma and hypertension. Patient data management system (PDMS) are systems that automatically retrieve data from bedside medical equipment (namely patient monitor, ventilator, intravenous pump, and so forth). The data is subsequently summarized and restructured to aid healthcare providers in interpreting the data. 45 Recent advances in integration have allowed PDMS to be integrated with clinical decision support and the patient's electronic medical record. A systematic review 45 studied the clinical impact of PDMS and found that such systems increased the time spent on direct patient care by reducing the time spent on charting. In addition, PDMS systems reduced the occurrence of errors (medication errors, ventilator incidents, intravenous incidents, and other incidents). The review also found that 2 articles reported an improvement in clinical outcomes when a PDMS was integrated with a clinical decision support system. Research shows that telemedicine technology seems to improve clinical outcomes for certain medical conditions and, seems to enhance accessibility to healthcare services and foster patient-physician collaboration. Apart from the limited evidence on PDMS, the impact of telemedicine on patient safety does not seem to be very clear.

Electronic incident reporting

Electronic incident reporting systems are web-based systems that allow healthcare providers who are involved in safety events to voluntarily report such incidents. Such systems can be integrated with the electronic health record (EHR) to enable abstraction of data and automated detection of adverse events through trigger tools. Electronic incident reporting systems potentially have the following advantages; standardize reporting structure, standardize incident action workflow, rapid identification of serious incidents and trigger events, while automating data entry and analysis. Published research shows that healthcare organizations that have moved to an electronic reporting system have experienced a significant increase in reporting frequency. 46 Incident reporting systems may improve clinical processes, but there is little evidence that electronic reporting systems ultimately reduce medical errors. 47

Overall impact of EMR on patient safety

Numerous studies have considered the outcomes of implementing an electronic medical record on healthcare quality and patient safety, with a majority of studies showing favorable results. Although, some studies demonstrated negative outcomes which continues to evoke dispute. Campanella et al 48 published perhaps the largest and most recent metaanalysis on the impact of electronic health records on healthcare quality and patient safety, which included 47 studies. The results favored the use of electronic medical records. The metaanalysis showed that organizations which implemented electronic health records had a 30% higher guideline adherence (RR= 1.33; 95% CI: 1.01 to 1.76; p=0.049), a reduction in medication errors by 54% (RR=0.46; 95% CI: 0.38 to 0.55; p<0.001) and a reduction in adverse drug reactions by 36% (RR=0.66; 95% CI: 0.44 to 0.99; p=0.045). The meta-analysis did not find any impact on overall mortality.

Discussion

There is substantial evidence that implementing an electronic medical record reduces medical errors and improves patient's safety. Computerized physician order entry and CDS are probably one of the most beneficial health information technologies for improving patient safety. In addition, ADC systems and PDMS seem to improve patient safety in critical care setting. Currently, there is insufficient evidence to reach a conclusion on patient safety outcomes for the following health information technologies; electronic sign-out and hand-off tools, smart pumps, bar-code medication administration, retained surgical items detectors, patient portals, telemedicine and electronic incident reporting. It is worth mentioning, that there is evidence that the aforementioned technologies seem to improve healthcare processes and non-safety outcomes Table 1 summarizes the evidence on various HIT technologies on patient safety.

Table 1

Published studies on health information technology exhibit variation in outcomes between different organizations when using the same technology. This has been attributed in the literature to the operationalization of health information technology within the complex adaptive health care system. Sittig and Singh 49 suggested a conceptual socio-technical model that accounts for key factors which influence the success of health information technology interventions. The 8 dimensions of their model are human-computer interface, workflow and communication, clinical content, internal organizational policies, people, hardware and software, external factors and system measurement and monitoring. The first 3 domains have been found by the Joint Commission to lead to 80% of health information technology sentinel events and serious adverse events and the Joint Commission subsequently recommended actions to improve HIT by focusing on 3 areas: safety culture, process improvement, and leadership. 50 The ONC has also published a series of guides called the "SAFER guide", which addresses electronic health record safety in a variety of areas (https://www.healthit.gov/safer/safer-guides).

The authors of this review recommend a comprehensive framework for organizations looking to improve patient safety outcomes when using health information technology which includes the following:

1. Health Information Governance. Organizations must establish a health information oversight mechanism that includes leadership and relevant stakeholders. In addition, organizations need to ensure that their health information plan is coordinated with the organization's patient safety and risk management plan.

2. Safety Risk Identification. Organizations need to identify areas that health information technology might aid in improving patient safety namely, medication safety, guideline adherence, and so forth.

3. Stake-Holder Involvement: Stakeholders need to be involved in all phases of health information projects from planning and implementation until continuous improvement. The most important stakeholder must be the system end-user and process owner.

4. Informed Decision: Organizations need to review the cost effectiveness of suggested technologies, which includes conducting an evidence based decision and an evaluation of the current information technology infrastructure including software and hardware.

5. Sufficient Training: Organizations need to ensure that all relevant line staff receive sufficient training on the use of the proposed health information technology.

6. Gradual Implementation: Rolling out the technology in a gradual stepped approach is crucial to avoid disruption of current processes and systems.

7. Continuous evaluation and monitoring of patient safety outcomes: Organizations need to measure patient safety outcomes on a continuous basis especially during the initial implementation to ensure that the new technology achieves its intended outcome.

8. Technology optimization: Organizations need to modify and finetune the implemented technology based on user feedback and patient safety outcomes.

9. Regular technology updates: Organizations must ensure that health information technologies are continuously updated to comply with recent best clinical practices, regulatory standards, and technical stability.

Study limitations

We studied the impact of a broad array of health information technologies which yielded studies with heterogeneous methodologies and interventions. Other sources of variability in the reviewed studies could be due to different vendors, software, quality, usability, and settings of implementation. Most studies on health information technology were in English, and we limited our search as such, which might result in the exclusion of relevant international articles.

In conclusion, health information technology improves patient safety by reducing medication errors, reducing adverse drug reactions and improving compliance to practice guidelines. There should be no doubt that health information technology is an important tool for improving healthcare quality and safety, but healthcare organizations need to be selective in which technology to invest in, as literature shows that some technologies have limited evidence in improving patient safety outcomes.

# data[].attributes.attachment_link.title
The impact of health information technology on patient safety

# data[].attributes.attachment_link.description
Since the original Institute of Medicine (IOM) report was published there has been an accelerated development and adoption of health information technology with varying degrees of evidence about the impact of health information technology on patient safety. ...

# data[].attributes.body
Alotaibi, Y. K., & Federico, F. (2017, December). The impact of health information technology on patient safety. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29209664

Blais and Hayes. (2016). Professional Nursing Practice: Concepts and Perspectives, 7th Edition. City of Greeley: University of Northern Colorado.

Bates, D. W. (2000). Using information technology to reduce rates of medication errors in hospitals. Bmj, 320(7237), 788–791. doi: 10.1136/bmj.320.7237.788

Lippincott Solutions (Ed.). (2017, June 14). Creating a Culture of Safety. Retrieved March 31, 2020, from http://lippincottsolutions.lww.com/blog.entry.html/2017/06/14/creating_a_cultureo-yjbq.html

https://www.psqh.com/analysis/from-smart-pumps-to-intelligent-infusion-systems-the-promise-of-interoperability/

# data[].attributes.body
Questions🤔