A study states that on the hospitalized side alone, drug-related side effects account for up to 44,000 deaths in the United States. We seek to answer the question of what are the most common factors that lead to errors in the Emergency Department.
CHAPTER II
ADVERSE EVENTS AT THE TIME OF DISCHARGE
A SYSTEMATIC LITERATURE REVIEW
Introduction
For example, dosing errors occur when poor physician handwriting is combined with a lack of medication dose verification in the hospital pharmacy and a lack of nursing supervision. In the first phase, two reviewers independently checked whether the title and abstract of the citations returned by the MEDLINE query met the inclusion criteria.
Results
In terms of ED processes involved in errors leading to ED discharge, no single process stood out. Among the most common processes responsible for errors in the ED were general diagnosis (18 articles), test interpretation (16 articles) and therapeutic intervention (15 articles).
Discussion
The integration of such a consultant with the electronic health record for entering medical orders in the emergency room would be ideal.
Limitations of systematic literature review
8 Goldberg's Frequency and Nature of Existing Moderate Adverse Drug Interactions in Incoming ED Patient Population. 21 Lerman <=1y frequency and nature of patient return visits to the ED within 72 hours of original visit.
Process Breakdowns in ED Errors
Adverse Events
Bibliography
Clinical features and natural history of patients with acute myocardial infarction sent home from the emergency room. Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study. Cause and effect analysis of risk management files to assess patient care in the emergency JW.
Cause and effect analysis of risk management files to assess patient care in the emergency department. Detecting and reducing adverse events in an Australian rural hospital emergency department using medical record review and review.
CHAPTER III
EVALUATION OF POTENTIALLY INAPPROPRIATE GERIATRIC
PRESCRIBINGH PRACTICES IN A TERTIARY CARE ACADEMIC EMERGENCY DEPARTMENT
There are a number of studies that have examined the prevalence of age-drug interactions in the outpatient population. However, to our knowledge, there have been no studies evaluating either the prevalence of pre-existing PIMs or the incidence rate of emergency department (ED) prescribing among Beers criteria drugs in a geriatric population. A large proportion of ambulatory care is provided by the ED and such care is provided by clinicians who are often under great time pressure and do not know the patient beforehand[6][7]. In this study, we sought to determine both the prevalence of potentially inappropriate medication use in patients presenting to a tertiary care, academic emergency department and the incidence of new PIM prescribing among ED physicians.
This study was conducted in the Emergency Department of Vanderbilt University Medical Center Emergency Department in Nashville, TN. An electronic whiteboard was installed in 2002 that tracks patient demographics, as well as interfaces with the ED computerized physician order entry system. All patients aged 65 or older who presented to the Adult Emergency Department from January 1, 2007 to December 31, 2008 and were subsequently discharged directly home from the ED were candidates for inclusion in this study.
For this reason, patients were excluded from the study if they were admitted to the hospital but continued to be placed in the ED, if they left the ED against medical advice, or if they left the ED after triage but before being seen by the ED physician. All patient-reported preexisting medications were collected from the PAML application program interface (API) using the PERL scripting language (version 5.1.0). A query of the Discharge 1-2-3 medication database revealed that 2,485 of the 5,430 cases received at least one script written by the Vanderbilt Adult ED during the same time period above.
Analysis
Comparing and contrasting the pre-existing medication list (PAML) and the discharge prescription list (DC123) gives us a lot of insights. The incidence of potentially inappropriate off-label medication appears at twice the frequency in the community than in the Adult ED. Not surprisingly, there were also many more types of medications potentially misprescribed in the community, as opposed to those written from the adult emergency department, where benzodiazepines were by far the predominant misprescribed medication.
Another interesting contrast is that the rate we report for the community (9%) appears much lower than that found in the literature in the general ambulatory community. Although we were able to adjust for indication-based dosing of the discharge medication and cross off the medications that were used appropriately, we were not. Second, due to the free-text nature of PAML, it often lacks full prescription descriptions ("ferrous sulfate" as opposed to "ferrous sulfate 325mg po tid").
As a stand-alone application, the user needs to remember the patient's medications and problem lists while writing new prescriptions. This system will undergo a prospective, randomized trial to determine whether it can reduce the incidence and prevalence of Beers criteria medication use in a geriatric population seen in the ED. Overcrowding in emergency departments: increased demand and decreased capacity, Annals of Emergency Medicine, April 2002 (Volume 39, Number 4, Pages 430-432).
CHAPTER IV
AN INTEGRATED FRAMEWORK FOR THE DISCHARGE OF PATIENTS FROM THE ADULT EMERGENCY DEPT
We have a fully functional order entry system, a home-grown EMR, and even a vendor-based download template system for writing prescriptions and patient instructions (Figure 5). The EMR and order entry system were developed in-house and, to a limited extent, interfaced with each other. Should there be an incidental finding in the ED that warrants follow-up, but does not.
The current system provides no protection against prescribing outpatient medications to which the patient may be allergic. We believe that the discharge process is central to preventing failure in the ED[2][3]. It can, and indeed should, serve as the last checkpoint before the patient leaves the ED and care is transferred to the ambulatory arena[3][4] (Figure 6).
ED clinicians should be required to review all orders performed in the ED as well as laboratory results before discharging the patient. This paper documents the process by which we developed a solution that successfully replaces a vendor-based solution with an in-house solution for patient discharge. In this paper, we document our goals for such a system, the process by which we built the system, how we rolled out the system, and present a status report on the current functionality of the system.
Design Objectives
In our application, we want to design a user interface based on well-established web interface heuristics. Navigation between different parts of the application should be done using the top navigation bar/tab or the left navigation pane. Current software licensing was dependent on the number of workstations on which the application was installed and prohibited installation of the program on a LAN.
We are working to remove this limitation in our application and allow it to run from any computer connected to our intranet. We fully integrate with EMR, CPOE, self-report medication list, prescription writer and patient instructions in our app. One of the virtues of a custom solution is the ability to modify the code at will to suit your own purposes.
In our application we try to output the data in the native format of our EMR and additionally store it in a fully relational database to facilitate standard SQL-based queries. No additional text parsing is required to extract meaningful data. One of the major weaknesses of the current system is the inability to automatically pass the relevant patient information to the next healthcare provider, apart from using the fax machine to fax the paper copy of the discharge documents. Optimal patient care requires good coordination between emergency physicians, nurses, case managers and follow-up physicians[4].
System Description
For the "View" we used JavaScript, HTML and CSS to render properly on the web browser. We used jQuery, which is a concise, Ruby-like JavaScript library that dramatically reduces coding and allows us to use AJAX (Asynchronous Javascript and XML) at scale for desktop-like performance in a web application. The AJAX is used by the "View" to communicate with the "Model" via a combination of straight text and JSON (javascript object notation - a much more concise alternative to XML) over a secure socket layer connection.
View" and not only promotes code management, but also allows the display of vast amounts of information that would otherwise not fit on the screen.
Functionality and Integration
Once an instruction is inserted, the user can navigate to it using links in the lower left pane (Figure 7). The user has the option to edit the instructions on the right side to further customize it. Clicking on the appropriate medication form on the left fills in the "Matching Directions" at the top right based on FirstDataBank's indication-based dosing information.
If you click on the instructions at the top right, the almost complete recipes will be inserted into the 'Recipes' section below. The user is free to re-edit previously written medications below by clicking the notepad icon, or delete the script in its entirety by clicking the red 'X'. If the follow-up is not in the local provider database, the user can click on the "Yahoo Phone Book" to search the Internet for the names of providers.
By hovering over the entries on the left, a business card like preview of the entire entry emerges. Clicking on the entries on the left will insert them into the panel on the right. With just a single click on the appropriate date on the calendar, the user can create an apology letter.
Discussion and Conclusion
As of this writing, the discharge application has been deployed in the Vanderbilt Adult ED for two months and has been used to discharge 991 patients so far. The app runs concurrently with the legacy system, which will be shut down once the app reaches > 90% approval rate. Hintz et al., Emergency departments and hoarding in United States teaching hospitals, Ann Emerg Med pp.
Gaps in communication and information transfer between hospital and primary care physicians: Implications for patient safety and continuity of care.
CHAPTER V
CONCLUSION
