Who adopts a patient portal?: An application of the diffusion of innovation model.

BACKGROUND: Patient portals have emerged as an important tool through which patients can access online health information and engage in their health care. However, we know little about how patients perceive portals and whether patient perceptions might influence portal adoption. OBJECTIVE: Apply the diffusion of innovation (DOI) theory to assess perceptions of adopters and non-adopters of a patient portal. METHODS: We conducted a cross-sectional survey of adopters and non-adopters of the portal. Our survey consisted of perceived attributes from the DOI theory, socio-demographic characteristics and patient perceptions of technology adoption. RESULTS: Three factors representing perceived attributes from DOI theory accounted for 73% of the variance in the data: Factor 1 - Relative Advantage (27%); Factor 2 - Ease of Use (24%) and Factor 3 - Trialability (22%). Adopters perceived greater Relative Advantage [mean (SD)] = 3.8 (0.71) versus 3.2 (0.89), p < 0.001, Ease of Use = 4.1 (0.71) versus 3.3 (0.95), p < 0.001 and Trialability = 4.0 (0.57) versus 3.4 (0.99), p < 0.001 than non-adopters. In multivariate modelling, age [OR = 3.75, 95% CI: (2.17, 6.46), p < 0.001] and income [OR = 1.87, 95% CI: (1.17, 3.00), p < 0.01] predicted adoption of the portal. Among DOI factors, Relative advantage predicted adoption of the portal [OR = 1.48, 95% CI: (1.03, 2.11), p < 0.05]. CONCLUSION: Patients will adopt a patient portal if they perceive it to offer a relative advantage over existing practices such as telephoning or visiting the doctor's office. Organisations seeking to increase the adoption of patient portals should implement strategies to promote the relative advantage of portals as, for example, through posters in waiting and exam rooms. A digital divide in the adoption of patient portals may exist with respect to age and income.

Physician Beliefs about the Meaningful Use of the Electronic Health Record: A Follow-Up Study.

Background There is continuing interest in how physicians are responding to the meaningful use of the electronic health record (EHR) incentive program. However, little research has been done on physician beliefs about the meaningful use of the EHR. Objective This study aims to conduct a follow-up study of physician beliefs about the meaningful use of the EHR. Methods Online survey of physicians at two academic medical centers (AMCs) in the northeast who were participating in the meaningful use of the EHR incentive program and were using an internally developed EHR was conducted. Results Of the 2,033 physicians surveyed, 1,075 completed the survey for an overall response rate of 52.9%. Only one-fifth (20.5%) of the physicians agreed or strongly agreed that meaningful use of the EHR would help them improve quality of care, and only a quarter (25.2%) agreed or strongly agreed that the meaningful use of the EHR would improve the care that their organization delivers. Physician satisfaction with the outpatient EHR was the strongest predictor of self-efficacy with achieving stage 2 of the meaningful use of the EHR incentive program (odds ratio: 2.10, 95% confidence interval: 1.61, 2.75, p < 0.001). Physicians reported more negative beliefs in stage 2 than stage 1 across all belief items. For example, 28.1% agreed or strongly agreed that the meaningful use of the EHR would decrease medical errors in stage 2 as compared with 35.9% in stage 1 (p < 0.001). Conclusion Only one-fifth of the physicians in our study believed that the meaningful use of the EHR would improve quality of care, patient-centeredness of care, or the care they personally provide. Primary care physicians expressed more negative beliefs about the meaningful use of the EHR in stage 2 than in stage 1. These findings show that physicians continue to express negative beliefs about the meaningful use of the EHR. These ongoing negative beliefs are concerning for both implementation and policy.

The denominator problem: national hospital quality measures for acute myocardial infarction.

BACKGROUND: National Hospital Quality Measures (NHQM) should accurately reflect quality of care, as they increasingly impact reimbursement and reputation. However, similar to risk adjustment of outcomes measures, NHQM process measures pose unique methodological concerns, including lack of representativeness of the final denominator population after exclusions. This study determines population size and characteristics for each acute myocardial infarction (AMI) measure, reasons for exclusion from the measures, and variation in exclusion rates among hospitals. METHODS AND RESULTS: 163 144 discharges from 172 University HealthSystem Consortium hospitals between 2008-Q4 and 2013-Q3 were examined, including characteristics and propensity scores of included and excluded groups. Measure exclusions ranged from 17.8% (discharge aspirin) to 90.1% (percutaneous coronary intervention, PCI, within 90 min), with substantial variation across hospitals. Median annual denominator size (IQR) for PCI within 90 min was 28 (20, 44) at major teaching hospitals, versus 10 (0, 25) at non-teaching hospitals. Patients most likely to be excluded (in the 10th vs 1st propensity decile) were older (mean age (SD) of 78.1 (10.8) vs 50.3 (8.6) years), more likely to have Medicare (90.5% vs 0.9%), had more documented comorbidities (15.6 (4.6) vs 6.2 (2.5) hierarchical clinical condition categories) and higher admission mortality risk (Major or Extreme 80.9% vs 7.3%, respectively), and experienced higher inpatient mortality (10.0% vs 1.6%). CONCLUSIONS: Exclusion from AMI measures varied substantially among hospitals, sample sizes were very small for some measures (PCI and ACE inhibitor measures) and measures often excluded high-risk populations. This has implications for the representativeness and comparability of the measures and provides insight for future measure development.

Patient perceptions of a personal health record: a test of the diffusion of innovation model.

BACKGROUND: Personal health records (PHRs) have emerged as an important tool with which patients can electronically communicate with their doctors and doctor's offices. However, there is a lack of theoretical and empirical research on how patients perceive the PHR and the differences in perceptions between users and non-users of the PHR. OBJECTIVE: To apply a theoretical model, the diffusion of innovation model, to the study of PHRs and conduct an exploratory empirical study on the applicability of the model to the study of perceptions of PHRs. A secondary objective was to assess whether perceptions of PHRs predict the perceived value of the PHR for communicating with the doctor's office. METHODS: We first developed a survey capturing perceptions of PHR use and other factors such as sociodemographic characteristics, access and use of technology, perceived innovativeness in the domain of information technology, and perceptions of privacy and security. We then conducted a cross-sectional survey (N = 1500). Patients were grouped into five groups of 300: PHR users (innovators, other users, and laggards), rejecters, and non-adopters. We applied univariate statistical analysis (Pearson chi-square and one-way ANOVA) to assess differences among groups and used multivariate statistical techniques (factor analysis and multiple regression analysis) to assess the presence of factors identified by the diffusion of innovation model and the predictors of our dependent variable (value of PHR for communicating with the doctor's office). RESULTS: Of the 1500 surveys, 760 surveys were returned for an overall response rate of 51%. Computer use among non-adopters (75%) was lower than that among PHR users (99%) and rejecters (92%) (P < .001). Non-adopters also reported a lower score on personal innovativeness in information technology (mean = 2.8) compared to 3.6 and 3.1, respectively, for users and rejecters (P < .001). Four factors identified by the diffusion of innovation model emerged in the factor analysis: ease of use, relative advantage, observability, and trialability. PHR users perceived greater ease of use and relative advantage of the PHR than rejecters and non-adopters (P < .001). Multiple regression analysis showed the following factors as significant positive predictors of the value of PHR for communicating with the doctor's office: relative advantage, ease of use, trialability, perceptions of privacy and security, age, and computer use. CONCLUSION: Our study found that the diffusion of innovation model fits the study of perceptions of the PHR and provides a suitable theoretical and empirical framework to identify the factors that distinguish PHR users from non-users. The ease of use and relative advantage offered by the PHR emerged as the most important domains among perceptions of PHR use and in predicting the value of the PHR. Efforts to improve uptake and use of PHRs should focus on strategies that enhance the ease of use of PHRs and that highlight the relative advantages of PHRs.

Association of National Hospital Quality Measure adherence with long-term mortality and readmissions.

BACKGROUND: In existing studies, the association between adherence with recommended hospital care processes and subsequent outcomes has been inconsistent. This has substantial implications because process measure scores are used for accountability, quality improvement and reimbursement. Our investigation addresses methodological concerns with previous studies to better clarify the process-outcomes association for three common conditions. METHODS: The study included all patients discharged from Massachusetts General Hospital between 1 July 2004 and 31 December 2007 with a principle diagnosis of acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PN) who were eligible for at least one National Hospital Quality Measure. The number of patients analysed varied by measure (374 to 3020) depending on Centers for Medicare and Medicaid Services eligibility criteria. Hospital data were linked with state administrative data to determine mortality and readmissions. For patients with multiple admissions, the time-weighted impact of measure failures on mortality was estimated using exponential decay functions. All patients had follow-up for at least 1 year or until death or readmission. Cox models were used to estimate HRs adjusted for transfer status, age, gender, race, census block-group socioeconomic status, number of Elixhauser comorbidities, and do not resuscitate orders. RESULTS: Adjusted survival and freedom from readmission for AMI and PN showed superior results for 100% and 50-99% adherence compared with 0-49% adherence. For HF, the results were inconsistent and sometimes paradoxical, although several individual measures (eg, ACE inhibitor/angiotensin receptor blockade) were associated with improved outcomes. CONCLUSION: Adherence with recommended AMI and PN care processes is associated with improved long-term outcomes, whereas the results for HF measures are inconsistent. The evidence base for all process measures must be critically evaluated, including the strength of association between these care processes and outcomes in real-world populations. Some currently recommended processes may not be suitable as accountability measures.

Improving the discharge process by embedding a discharge facilitator in a resident team.

BACKGROUND: Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow-up, and hospital reutilization. METHODS: A 5-month randomized controlled trial was conducted on the medical service at an academic tertiary-care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients. RESULTS: Intervention patients had more discharge summaries completed within 24 hours (67% vs. 47%, P < 0.001). Similarly, they had more follow-up appointments scheduled by the time of discharge (62% vs. 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs. 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs. 85%, P = 0.003) and were more satisfied with the discharge process (97% vs. 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs. 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30-day emergency department visits or readmissions. CONCLUSIONS: Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population.

Risk of thiazide-induced hyponatremia in patients with hypertension.

BACKGROUND: Although hyponatremia is a well-recognized complication of treatment with thiazide diuretics, the risk of thiazide-induced hyponatremia remains uncertain in routine care. METHODS: We conducted a retrospective cohort study using a multicenter clinical research registry to identify 2613 adult outpatients that were newly treated for hypertension between January 1, 2000 and December 31, 2005 at 2 teaching hospitals in Boston, Massachusetts, and followed them for up to 10 years. RESULTS: Two hundred twenty patients exposed to ongoing thiazide therapy were compared with 2393 patients who were not exposed. In the exposed group, 66 (30%) developed hyponatremia (sodium ≤130 mmol/L). The adjusted incidence rate of hyponatremia was 140 cases per 1000 person-years for patients treated with thiazides, compared with 87 cases per 1000 person-years in those without thiazides. Patients exposed to thiazides were more likely to develop hyponatremia (adjusted incidence rate ratio, 1.61; 95% confidence interval [CI], 1.15-2.25). There was no significant difference in the risk of hospitalizations associated with hyponatremia (adjusted rate ratio, 1.04; 95% CI, 0.46-2.32) or mortality (adjusted rate ratio, 0.41; 95% CI, 0.12-1.42). The number needed to harm (to result in one excess case of incident hyponatremia in 5 years) was 15.02 (95% CI, 7.88-160.30). CONCLUSIONS: Approximately 3 in 10 patients exposed to thiazides who continue to take them develop hyponatremia.

Predictors of nonadherence to national hospital quality measures for heart failure and pneumonia.

BACKGROUND: Understanding factors associated with process measure nonadherence may improve both patient care and future measure design. METHODS: We analyzed 3401 patients with heart failure and 2186 patients with pneumonia who were eligible for at least 1 National Hospital Quality Measure at an urban tertiary medical center from July 1, 2004, to June 30, 2008. We investigated the association of socioeconomic, demographic, clinical, and care delivery factors with process measure nonadherence, using multivariable analysis. RESULTS: Demographic and socioeconomic variables were unrelated to heart failure measure adherence. Nonadherence with angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was more common in patients with renal failure (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.46-4.49), and patients admitted to noncardiac units more often failed the heart failure all-or-none measure (OR 2.22; 95% CI, 1.79-2.75). Patients with pneumonia who were admitted via the emergency department were less likely to fail antibiotic timing (OR 0.41; 95% CI, 0.27-0.63), whereas those with a history of methicillin-resistant Staphylococcus aureus (OR 2.63; 95% CI, 1.31-5.28) or requiring intensive care unit admission (OR 11.4; 95% CI, 6.3-20.8) were more likely to fail the antibiotic selection measure. CONCLUSION: Demographic and socioeconomic factors were generally unrelated to process measure nonadherence, demonstrating that excellent inpatient care can be delivered even to vulnerable populations. Clinical predictors suggest opportunities for improving both medical record documentation of appropriate exclusions and future measure specifications, especially for complex patients. Care delivery factors substantially affect process adherence.

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.

The digital divide in adoption and use of a personal health record.

BACKGROUND: Personal health records (PHRs) offer the potential to improve the patient experience and the quality of patient care. However, the "digital divide," the population-level gap in Internet and computer access, may prevent certain groups from accessing the PHR. METHODS: We conducted a cross-sectional analysis of a PHR within a northeastern health system. We compared adopters (ie, those activating a PHR account online) with nonadopters (ie, those who see a physician offering the PHR but do not activate an account). We further categorized adopters by intensity of PHR use, measured by number of log-ins and number of messages sent to physicians' practices. RESULTS: As of September 30, 2009, among 75,056 patients, 43% had adopted the PHR since 2002. Blacks and Hispanics were less likely to adopt the PHR compared with whites (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.45-0.55; and 0.64; 0.57-0.73, respectively), and those with lower annual income were less likely to adopt the PHR than were those with higher income. Compared with nonadopters, adopters were more likely to have more than 2 comorbidities (OR, 1.27; 95% CI, 1.17-1.30). Use of an aggressive marketing strategy for PHR enrollment increased adoption nearly 3-fold (OR, 2.92; 95% CI, 1.58-5.40). Intensity of use was best predicted by increasing number of comorbidities, followed by race/ethnicity (whites more than blacks and Hispanics) and insurance status. We found no association between income and log-in frequency or secure messages sent. CONCLUSIONS: Despite increasing Internet availability, racial/ethnic minority patients adopted a PHR less frequently than white patients, and patients with the lowest annual income adopted a PHR less often than those with higher incomes. Among adopters, however, income did not have an effect on PHR use.

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. We used multivariate analysis to identify independent risk factors for non-adherence to BBWs. RESULTS: There was a slightly higher frequency of non-adherence to BBWs after the intervention (4.8% vs. 5.1%, p=0.045). In multivariate analyses, after adjustment for patient and provider characteristics and site of care, medications prescribed during the pre-intervention period were less likely to violate BBWs compared to those prescribed during the post-intervention period (OR 0.67, 95% CI, 0.47-0.96). However, black-box warning violations did decrease after the intervention for BBWs about drug-drug interactions (6.1% vs. 1.8%, p<0.0001) and drug-pregnancy interactions (5.1% vs. 3.6%, p=0.01). CONCLUSIONS: Ambulatory care computerized order entry with prescribing alerts about BBWs did not improve clinicians' overall adherence to BBWs, though it did improve adherence for specific clinically important subcategories.

Lessons learned from implementation of a computerized application for pending tests at hospital discharge.

BACKGROUND: Patients are often discharged from the hospital before test results are finalized. Awareness of these results is poor and therefore an important patient safety concern. Few computerized systems have been deployed at care transitions to address this problem. We describe an attempt to implement a computerized application to help inpatient physicians manage these test results. METHODS: We modified an ambulatory electronic medical record (EMR)-based results management application to track pending tests at hospital discharge (Hospitalist Results Manager, HRM). We trained inpatient physicians at 2 academic medical centers to track these tests using this application. We surveyed inpatient physicians regarding usage of and satisfaction with the application, barriers to use, and the characteristics of an ideal system to track pending tests at discharge. RESULTS: Of 29 survey respondents, 14 (48%) reported never using HRM, and 13 (45%) used it 1 to 2 times per week. A total of 23 (79%) reported barriers prohibiting use, including being inundated with clinically "irrelevant" results, not having sufficient time, and a lack of integration of post-discharge test result management into usual workflow. Twenty-one (72%) wanted to receive notification of abnormal and clinician-designated pending test results. Twenty-seven physicians (93%) agreed that an ideally designed computerized application would be valuable for managing pending tests at discharge. CONCLUSIONS: Although inpatient physicians would highly value a computerized application to manage pending tests at discharge, the characteristics of an ideal system are unclear and there are important barriers prohibiting adoption and optimal usage of such systems. We outline suggestions for future electronic systems to manage pending tests at discharge.

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

BACKGROUND: Medication reconciliation at transitions in care is a national patient safety goal, but its effects on important patient outcomes require further evaluation. We sought to measure the impact of an information technology-based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]). METHODS: We performed a controlled trial, randomized by medical team, on general medical inpatient units at 2 academic hospitals from May to June 2006. We enrolled 322 patients admitted to 14 medical teams, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. The main outcome was unintentional discrepancies between preadmission medications and admission or discharge medications that had potential for harm (PADEs). RESULTS: Among 160 control patients, there were 230 PADEs (1.44 per patient), while among 162 intervention patients there were 170 PADEs (1.05 per patient) (adjusted relative risk [ARR], 0.72; 95% confidence interval [CI], 0.52-0.99). A significant benefit was found at hospital 1 (ARR, 0.60; 95% CI, 0.38-0.97) but not at hospital 2 (ARR, 0.87; 95% CI, 0.57-1.32) (P = .32 for test of effect modification). Hospitals differed in the extent of integration of the medication reconciliation tool into computerized provider order entry applications at discharge. CONCLUSIONS: A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.

Hospital readmissions: physician awareness and communication practices.

BACKGROUND: Patients requiring early hospital readmission may be readmitted to different physicians, potentially without the knowledge of the prior caregivers. This lost opportunity to share information about readmitted patients may be detrimental to quality of care and resident education. OBJECTIVE: To measure physician awareness of and communication about readmissions. DESIGN: Cross-sectional study. SETTING: Two academic medical centers. PARTICIPANTS: A total of 432 patients discharged from the general medicine services and readmitted within 14 days. MEASUREMENTS: We identified patients discharged from the general medicine services and readmitted within 14 days, excluding patients readmitted to the same physician(s) and planned readmissions. We surveyed discharging and readmitting physicians 48 h after the time of readmission. RESULTS: Discharging physician teams were aware of 48.5% (95% CI 41.5%-55.5%) of patient readmissions. Communication between teams occurred on 43.7% (95% CI 37.1%-50.3%). Higher medical complexity was associated with an increased likelihood of physician communication (adjusted OR 1.12, 95% CI 1.06-1.19). When communication occurred, readmitting physicians received information about the discharging team's overall assessment (61.9%, 95% CI 51.9%-71.9%), psychosocial issues (52.6%, 95% CI 42.4%-62.8%), pending tests (34.0%, 95% CI 24.2%-43.8%), and discharge medications (30.9%, 95% CI 21.5%-40.3%). When communication did not occur, most physicians (60.8%, 95% CI 56.7%-64.9%) responded it would have been desirable to communicate. CONCLUSIONS: Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.

Handoffs causing patient harm: a survey of medical and surgical house staff.

BACKGROUND: Communication lapses at the time of patient handoffs are believed to be common, and yet the frequency with which patients are harmed as a result of problematic handoffs is unknown. Resident physicians were surveyed about their handoffpractices and the frequency with which they perceive problems with handoffs lead to patient harm. METHODS: A survey was conducted in 2006 of all resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) concerning the quality and effects of handoffs during their most recent inpatient rotations. Surveys were sent to 238 eligible residents; 161 responses were obtained (response rate, 67.6%). RESULTS: Fifty-nine percent of residents reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that this harm had been major. Overall quality of handoffs was reported to be fair or poor by 31% of residents. A minority of residents (26%) reported that handoffs usually or always took place in a quiet setting, and 37% reported that one or more interruptions during the receipt of handoffs occurred either most of the time or always. DISCUSSION: Although handoffs have long been recognized as potentially hazardous, further scrutiny of handoffs has followed recent reports that handoffs are often marked by missing, incomplete, or inaccurate information and are associated with adverse events. In this study, reports of harm to patients from problematic handoffs were common among residents in internal medicine and general surgery. Many best-practice recommendations for handoffs are not observed, although the extent to which improvement of these practices could reduce patient harm is not known. MGH has recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs, for its house staff and clinical leadership.

Successful implementation of an alcohol-withdrawal pathway in a general hospital.

BACKGROUND: Although alcohol use and abuse are common among general-hospital inpatients, many patients are inadequately assessed and treated for alcohol withdrawal. OBJECTIVE: The purpose of this study was to determine whether the implementation of a clinical pathway for the treatment of alcohol withdrawal in medical inpatients would result in improvements in clinical practice and patient outcomes. METHOD: Authors retrospectively reviewed 80 patient records (including 40 of those treated before the implementation of a pathway and 40 of those treated after pathway implementation). RESULTS: Assessment procedures and ordering patterns of physicians (medical house staff and staff physicians) shifted in a fashion consistent with the new treatment guidelines. Patient outcomes (e.g., length of stay and the incidence of delirium) improved for those patients who received benzodiazepines within the range of the pathway guidelines. CONCLUSIONS: Timely assessment and staff education can shift prescription patterns, increase patient monitoring, and reduce costs associated with alcohol withdrawal.

Classifying and predicting errors of inpatient medication reconciliation.

BACKGROUND: Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur. OBJECTIVE: To determine the reasons, timing, and predictors of potentially harmful medication discrepancies. DESIGN: Prospective observational study. PATIENTS: Admitted general medical patients. MEASUREMENTS: Study pharmacists took gold-standard medication histories and compared them with medical teams' medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs). RESULTS: Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs. CONCLUSIONS: Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.

Using computerized provider order entry application to improve compliance with co-signature of verbal orders.

Verbal orders that are not cosigned in a timely manner represent potential quality, safety, and medical-legal concerns. Computerized Provider Order Entry Systems (CPOEs) provide unique opportunities to understand, describe, and improve compliance with guidelines that require the timely co-signature of verbal orders. We describe our baseline compliance and improvements that were achieved through a series of CPOE interventions and related provider feedback and education.