Search tips
Search criteria

Results 1-16 (16)

Clipboard (0)

Select a Filter Below

Year of Publication
Document Types
1.  Development of a primary care physician task list to evaluate clinic visit workflow 
BMJ quality & safety  2011;21(1):47-53.
Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit.
A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings.
The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student.
The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.
PMCID: PMC3568931  PMID: 21896667
2.  Factors contributing to an increase in duplicate medication order errors after CPOE implementation 
To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors.
CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs).
Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors.
Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered.
Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.
PMCID: PMC3198002  PMID: 21803925
Human factors; EHR; informatics
3.  Human factors systems approach to healthcare quality and patient safety 
Applied ergonomics  2013;45(1):14-25.
Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.
PMCID: PMC3795965  PMID: 23845724
sociotechnical system; macroergonomics; health care; patient safety; SEIPS model; balanced work system; patient-centered care; healthcare team
4.  Macroergonomics in Healthcare Quality and Patient Safety 
The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.
PMCID: PMC3981462  PMID: 24729777
macroergonomics; work system; sociotechnical system; organizational context; SEIPS model; healthcare quality; patient safety; patient-centered care; care coordination; job stress; workload; interruptions; system design; mixed methods research
5.  Changes in end-user satisfaction with Computerized Provider Order Entry over time among nurses and providers in intensive care units 
Implementation of Computerized Provider Order Entry (CPOE) has many potential advantages. Despite the potential benefits of CPOE, several attempts to implement CPOE systems have failed or met with high levels of user resistance. Implementation of CPOE can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users’ needs and the significant workflow changes required by CPOE. User satisfaction is a critical factor in information technology implementation. Little is known about how end-user satisfaction with CPOE changes over time.
To examine ordering provider and nurse satisfaction with CPOE implementation over time.
We conducted a repeated cross-sectional questionnaire survey in four intensive care units of a large hospital. We analyzed the questionnaire data as well as the responses to two open-ended questions about advantages and disadvantages of CPOE.
Users were moderately satisfied with CPOE and there were interesting differences between user groups: ordering providers and nurses. User satisfaction with CPOE did not change over time for providers, but it did improve significantly for nurses. Results also show that nurses and providers are satisfied with different aspects of CPOE.
PMCID: PMC3638190  PMID: 23100129
Medical Order Entry Systems; Satisfaction; Repeated Rounds of Surveys; Intensive Care Units
6.  Characterizing the Complexity of Medication Safety using a Human Factors Approach: An Observational Study in Two Intensive Care Units 
BMJ quality & safety  2013;23(1):56-65.
To examine medication safety in two ICUs and to assess the complexity of medication errors and adverse drug events (ADEs) in ICUs across the stages of the medication-management process.
Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (e.g., medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process.
An average of 2.9 preventable or potential ADEs occurred in each admission, i.e., 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1,000 patient-days was 276, whereas the rate of preventable ADEs per 1,000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16–24% of potential and preventable ADEs, clusters of errors occurred either as sequence of errors (e.g., delay in medication dispensing leading to delay in medication administration) or grouped errors (e.g., route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process.
Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerized physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.
PMCID: PMC3938094  PMID: 24050986
medication safety; medication errors; adverse drug events; intensive care unit; human factors engineering
7.  Conducting an Efficient Proactive Risk Assessment Prior to CPOE Implementation in an Intensive Care Unit 
To develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU.
We developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term).
Sixteen unique relevant vulnerabilities were identified as a result of the PRA team’s efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing “issues list” of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n = 7) or shortly thereafter (n = 9). No other issues were identified beside those identified by the team.
Generally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.
PMCID: PMC3430828  PMID: 22608242
Risk assessment; CPOE; Electronic health records; Intensive care units; Human factors engineering
8.  Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS) 
Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.
Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.
At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.
Trial registration identifier NCT01337063
PMCID: PMC3698100  PMID: 23800355
Medication reconciliation; Hospitalization; Quality improvement; Care transitions
9.  Do Hospitalists Affect Clinical Outcomes and Efficiency for Patients with Acute Upper Gastrointestinal Hemorrhage (UGIH)? 
Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and non-hospitalists.
The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (i.e., recurrent bleeding, ICU-transfer, decompensation, transfusion, re-endoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS).
Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson index. Unadjusted clinical outcomes between hospitalists and non-hospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; p=.02) or be re-admitted within 30-days (7.3% vs. 3.3%; p=.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and non-hospitalists (4 days; p=.69), but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181; p<.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; p=.15) and costs remained higher for the hospitalist-led teams (p<0.03).
Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.
PMCID: PMC3587174  PMID: 20235292
Gastrointestinal hemorrhage; hospitalists; outcomes; length of stay; costs
10.  Worklife and Satisfaction of Hospitalists: Toward Flourishing Careers 
The number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.
Determine current satisfaction levels among hospitalists.
Survey study.
A national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored.
There were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort.
Hospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.
PMCID: PMC3250553  PMID: 21773849
hospital medicine; survey research; workforce; satisfaction; worklife
11.  ICU nurses' acceptance of electronic health records 
To assess intensive care unit (ICU) nurses' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.
The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.
Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.
On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.
As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.
PMCID: PMC3197984  PMID: 21697291
Human factors; EHR; Geisinger
12.  Information Chaos in Primary Care: Implications for Physician Performance and Patient Safety 
The purpose of this paper is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.
We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.
Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, its consequences, discuss possible solutions and suggest a research agenda which may lead to methods to reduce the problem.
Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.
PMCID: PMC3286113  PMID: 22086819
Primary Health Care; Information Management/Informatics; Complexity Science; Medical Errors; Practice Management
13.  Nurses’ Acceptance of Smart IV Pump Technology 
“Smart” intravenous infusion pumps (Smart IV pumps) are increasingly being implemented in hospitals to reduce medication administration errors.
This study examines nurses’ experience with the implementation and use of a Smart IV pump in an academic hospital.
Data were collected in three longitudinal surveys: (a) a pre-implementation survey, (b) a 6-week-post-implementation survey, and (c) a 1-year-post-implementation survey. We examined: (a) the technology implementation process, (b) technical performance of the pump, (c) usability of the pump, and (d) user acceptance of the pump.
Initially, nurses had a somewhat positive acceptance of the Smart IV pump technology that significantly increased one year after implementation. User experiences associated with the pump in general improved over time, especially perceptions of pump efficiency. However, user experience with the pump implementation process and pump technical performance did not consistently improve from the pre-implementation survey to the post-implementation survey. Several characteristics of pump technical performance and usability influenced user acceptance at the one-year post-implementation survey.
These data may be useful for other institutions to guide implementation and post-implementation follow-up of IV pump use; other institutions could use the survey instrument from this study to evaluate nurses’ perceptions of the technology. Our study identified several characteristics of the implementation process that other institutions may need to pay attention to (e.g., sharing information about the implementation process with nurses).
PMCID: PMC2862878  PMID: 20219423
infusion pump; acceptance process; safety management; Smart IV pump technology; user acceptance; nurses; survey
14.  Hospital Readmission in General Medicine Patients: A Prediction Model 
Previous studies of hospital readmission have focused on specific conditions or populations and generated complex prediction models.
To identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk.
Prospective observational cohort study.
Participants encompassed 10,946 patients discharged home from general medicine services at six academic medical centers and were randomly divided into derivation (n = 7,287) and validation (n = 3,659) cohorts.
We identified readmissions from administrative data and 30-day post-discharge telephone follow-up. Patient-level factors were grouped into four categories: sociodemographic factors, social support, health condition, and healthcare utilization. We performed logistic regression analysis to identify significant predictors of unplanned readmission within 30 days of discharge and developed a scoring system for estimating readmission risk.
Approximately 17.5% of patients were readmitted in each cohort. Among patients in the derivation cohort, seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity index, SF12 physical component score, ≥1 admission(s) within the last year, and current length of stay >2 days. A cumulative risk score of ≥25 points identified 5% of patients with a readmission risk of approximately 30% in each cohort. Model discrimination was fair with a c-statistic of 0.65 and 0.61 for the derivation and validation cohorts, respectively.
Select patient characteristics easily available shortly after admission can be used to identify a subset of patients at elevated risk of early readmission. This information may guide the efficient use of interventions to prevent readmission.
PMCID: PMC2839332  PMID: 20013068
hospital; readmission; predictive; model
15.  Association of Communication Between Hospital-based Physicians and Primary Care Providers with Patient Outcomes 
Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.
We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient’s PCP was associated with the 30-day composite outcome.
A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 – 1.34), the presence of a discharge summary (0.84, 95% CI 0.57–1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73–1.59).
Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample.
PMCID: PMC2642573  PMID: 19101774
hospitalist care; continuity of care; physician communication
16.  Effect of the Inpatient General Medicine Rotation on Student Pursuit of a Generalist Career 
Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain.
To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM.
Multicenter cohort study.
Third-year medical students between July 2001 and June 2003.
End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of “Very Likely” or “Certain” to the question “How likely are you to pursue a career in GIM?”; and (2) entry into an internal medicine residency using institutional match data.
Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01).
Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.
PMCID: PMC1484782  PMID: 16704390
medical student; career interest; general internal medicine

Results 1-16 (16)