Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study.

Background: Adverse event surveillance approaches underestimate the prevalence of harmful diagnostic errors (DEs) related to hospital care.

Methods: We conducted a single-centre, retrospective cohort study of a stratified sample of patients hospitalised on general medicine using four criteria: transfer to intensive care unit (ICU), death within 90 days, complex clinical events, and none of the aforementioned high-risk criteria. Cases in higher-risk subgroups were over-sampled in predefined percentages.

Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study.

Importance: The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange.

Objective: To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes.

Design: Prospective interventional cohort study.

Comparison of Medication Alerts from Two Commercial Applications in the USA.

Introduction: Medication organizations across the USA have adopted electronic health records, and one of the most anticipated benefits of these was improved medication safety, but alert fatigue has been a major issue.

Objective: We compared the appropriateness of medication-related clinical decision support alerts triggered by two commercial applications: EPIC and Seegnal's platform.

Methods: This was a retrospective comparison of two commercial applications.

Clinical Characteristics and Severity of COVID-19 Disease in Patients from Boston Area Hospitals.

We summarize key demographic, clinical, and medical characteristics of patients with respect to the severity of COVID-19 disease using Electronic Health Records Data of 4,140 SARS-CoV-2 positive subjects from several large Boston Area Hospitals. We found that prior use of antihypertensive medications as well as lipid lowering and other cardiovascular drugs (such as direct oral anticoagulants and antiplatelets) all track with increased severity of COVID-19 and should be further investigated with appropriate adjustment for confounders such as age and frailty. The three most common prior comorbidities are hyperlipidemia, hypertension, and prior pneumonia, all associated with increased severity.

Lab monitoring and acute care utilization during initiation of renin angiotensin aldosterone inhibitors or diuretics in chronic kidney disease.

Renin angiotensin aldosterone system inhibitors (RAASi) and diuretics are among the most frequently prescribed anti-hypertensives. Individuals with chronic kidney disease (CKD) are particularly at risk for electrolyte disturbances and kidney injury but the appropriate use of lab monitoring following RAASi or diuretic initiation is uncertain in CKD.We describe the frequency and time interval of lab monitoring during initiation of RAASi and diuretics in CKD and assess whether close lab monitoring associates with one-year risk of emergency department (ED) visit or hospitalization.

The Burden of Opioid-Related Adverse Drug Events on Hospitalized Previously Opioid-Free Surgical Patients.

Objective: Opioid analgesics are a mainstay for acute pain management, but postoperative opioid administration has risks. We examined the prevalence, risk factors, and consequences of opioid-related adverse drug events (ORADEs) in a previously opioid-free surgical population.

Methods: A retrospective, observational, cohort study using administrative, billing, clinical, and medication administration data from two hospitals.

Association of Changes in Creatinine and Potassium Levels After Initiation of Renin Angiotensin Aldosterone System Inhibitors With Emergency Department Visits, Hospitalizations, and Mortality in Individuals With Chronic Kidney Disease.

Importance: Renin angiotensin aldosterone system inhibitors (RAASIs) benefit individuals with chronic kidney disease (CKD). Elevations in serum creatinine and potassium levels are common reasons for discontinuation of this therapy, but their incidence and risks are not well characterized in community practice.

Objective: To evaluate associations of increased creatinine levels, hyperkalemia, and therapy continuation with the risk of emergency department (ED) visits, hospitalizations, and mortality within 1 year after RAASI therapy initiation in individuals with CKD.

Evaluation of 'Definite' Anaphylaxis Drug Allergy Alert Overrides in Inpatient and Outpatient Settings.

Introduction: Drug-allergy interaction (DAI) alerts are generated when a known adverse sensitivity-inducing substance is prescribed. A recent study at our institution showed that providers overrode most DAI alerts, including those that warned against potentially life-threatening 'anaphylaxis'.

Objective: The aim of this study was to determine the rate of anaphylaxis overrides, the reasons for these overrides, whether the overrides were appropriate, and if harm occurred from overrides.

Medication-related clinical decision support alert overrides in inpatients.

Objective: To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons.

Materials And Methods: We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons.

Comparison of Overridden Medication-related Clinical Decision Support in the Intensive Care Unit between a Commercial System and a Legacy System.

Background: Electronic health records (EHRs) with clinical decision support (CDS) have shown to be effective at improving patient safety. Despite this, alerts delivered as part of CDS are overridden frequently, which is of concern in the critical care population as this group may have an increased risk of harm. Our organization recently transitioned from an internally-developed EHR to a commercial system.

Review of Nonformulary Medication Approvals in an Academic Medical Center.

Background: The Joint Commission requires hospitals to formally review formulary medications at least annually based on new clinical information. Although review of nonformulary medication (NFM) use is not required, frequent and inappropriate use of NFMs has the potential to increase hospital costs, negatively affect quality of care, and increase medication errors. Limited resources may restrict an institution's ability to review NFM use in addition to the required annual formulary review.

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

Purpose: Medication-related clinical decision support (CDS) has been identified as a method to improve patient outcomes but is historically frequently overridden and may be inappropriately so. Patients in the intensive care unit (ICU) are at a higher risk of harm from adverse drug events (ADEs) and these overrides may increase patient harm. The objective of this study is to determine appropriateness of overridden medication-related CDS overrides in the ICU.

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

Background: Experts suggest that formulary alerts at the time of medication order entry are the most effective form of clinical decision support to automate formulary management.

Objective: Our objectives were to quantify the frequency of inappropriate nonformulary medication (NFM) alert overrides in the inpatient setting and provide insight on how the design of formulary alerts could be improved.

Methods: Alert overrides of the top 11 (n = 206) most-utilized and highest-costing NFMs, from January 1 to December 31, 2012, were randomly selected for appropriateness evaluation.

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.

Objectives: To evaluate how often and why providers overrode drug allergy alerts in both the inpatient and outpatient settings.

Design: A cross-sectional observational study of drug allergy alerts generated over a 3-year period between 1 January 2009 and 31 December 2011.

Setting: A 793-bed tertiary care teaching affiliate of Harvard Medical School and 36 primary care practices.

The effect of provider characteristics on the responses to medication-related decision support alerts.

Background: Improving the quality of prescribing and appropriate handling of alerts remains a challenge for design and implementation of clinical decision support (CDS) and comparatively little is known about the effects that provider characteristics have on how providers respond to medication alerts.

Objectives: To investigate the relationship between provider characteristics and their response to medication alerts in the outpatient setting.

Design And Participants: Retrospective observational study using a prescription log from the automated electronic outpatient system for each of 478 providers using the system at primary care practices affiliated with 2 teaching hospitals, from 2009 to 2011 for six types of alerts.

Overrides of medication-related clinical decision support alerts in outpatients.

Background: Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue.

Objective: To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides.

Impact of implementing alerts about medication black-box warnings in electronic health records.

Background: The Food and Drug Administration issues black-box warnings (BBWs) regarding medications with serious risks, yet physician adherence to the warnings is low.

Methods: We evaluated the impact of delivering BBW-based alerts about drug-drug, drug-disease, and drug-laboratory interactions for prescription medications in outpatients in an electronic health record with clinical decision support. We compared the frequency of non-adherence to all BBWs about drug-drug, drug-disease, and drug-laboratory interactions for 30 drugs/drug classes, and by individual drugs/drug groups with BBWs between the pre- and post-intervention periods.

A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.

Objective: Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring.

Design: We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004.

Improving override rates for computerized prescribing alerts in ambulatory care.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. We developed a selective knowledge base of only clinically significant drug alerts and designated only critical-high severity alerts to be interruptive to clinician workflow (a tiered approach). Using this approach, we were able to achieve a 67% clinician accept rate for ambulatory computerized prescribing alerts.

Adherence to black box warnings for prescription medications in outpatients.

Background: Few data are available regarding the prevalence of potentially dangerous drug-drug, drug-laboratory, and drug-disease interactions among outpatients. Our objectives were to determine how frequently clinicians prescribe drugs in violation of black box warnings for these issues and to determine how frequently such prescribing results in harm.

Methods: In an observational study of 51 outpatient practices using an electronic health record, we measured the frequency with which patients received prescriptions in violation of black box warnings for drug-drug, drug-laboratory, and/or drug-disease interactions.

Improving acceptance of computerized prescribing alerts in ambulatory care.

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices.

A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease.

Objective: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.

Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care.

An evaluation of risk factors for adverse drug events associated with angiotensin-converting enzyme inhibitors.

Rationale, Aims And Objectives: To identify potential factors leading to discontinuation of angiotensin-converting enzyme (ACE) inhibitors because of adverse drug events.

Methods: Retrospective cohort study was conducted at outpatient clinics affiliated with an urban tertiary care hospital. ACE inhibitors were administered to 2225 consecutive outpatients.

Development and validation of a clinical prediction rule for angiotensin-converting enzyme inhibitor-induced cough.

Background: Angiotensin-converting enzyme inhibitors are effective for many cardiovascular diseases and are widely prescribed, but cough sometimes necessitates their withdrawal.

Objective: To develop and validate a model that predicts, by using information available at first prescription, whether a patient will develop cough within 6 months.

Design: Retrospective cohort study with derivation and validation sets.

Electronically screening discharge summaries for adverse medical events.

Objective: Detecting adverse events is pivotal for measuring and improving medical safety, yet current techniques discourage routine screening. The authors hypothesized that discharge summaries would include information on adverse events, and they developed and evaluated an electronic method for screening medical discharge summaries for adverse events.

Design: A cohort study including 424 randomly selected admissions to the medical services of an academic medical center was conducted between January and July 2000.