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Research paper thumbnail of Dashboard Visualizations: Supporting Real-Time Throughput Decision-Making

Journal of biomedical informatics, Jul 1, 2017

Providing timely and effective care in the emergency department (ED) requires the management of i... more Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizatio...

Research paper thumbnail of Improved Accuracy and Quality of Information During Emergency Department Care Transitions

The western journal of emergency medicine, 2017

Suboptimal communication during emergency department (ED) care transitions has been shown to cont... more Suboptimal communication during emergency department (ED) care transitions has been shown to contribute to medical errors, sometimes resulting in patient injury and litigation. The study objective was to determine whether a standardized checkout process would decrease the number of relevant missed clinical items (MCI). In this prospective pre- and post-intervention study conducted in an urban academic ED, we collected data on omitted or inaccurately conveyed medical information before and after the initiation of a standardized checkout process. The intervention included group checkout in an optimal location, review of electronic medical records, case discussion and assigned roles. MCI were considered relevant if they resulted in a delay or alteration in disposition or treatment plan. The primary outcome was the change in the number of MCI. Secondary outcomes were duration of checkout and physician satisfaction with the intervention. Pre-intervention, there were 94 relevant MCI durin...

Research paper thumbnail of Improved Accuracy and Quality of Information During Emergency Department Care Transitions

Western Journal of Emergency Medicine

Introduction: Suboptimal communication during emergency department (ED) care transitions has been... more Introduction: Suboptimal communication during emergency department (ED) care transitions has been shown to contribute to medical errors, sometimes resulting in patient injury and litigation. The study objective was to determine whether a standardized checkout process would decrease the number of relevant missed clinical items (MCI). Methods: In this prospective pre-and post-intervention study conducted in an urban academic ED, we collected data on omitted or inaccurately conveyed medical information before and after the initiation of a standardized checkout process. The intervention included group checkout in an optimal location, review of electronic medical records, case discussion and assigned roles. MCI were considered relevant if they resulted in a delay or alteration in disposition or treatment plan. The primary outcome was the change in the number of MCI. Secondary outcomes were duration of checkout and physician satisfaction with the intervention. Results: Pre-intervention, there were 94 relevant MCI during 164 care transitions. Post-intervention, there were 36 MCI in 157 transitions. The mean MCI per transition decreased by 58% from 0.57 (95% confidence interval [CI] [0.41, 0.73]) to 0.23 (95% CI [0.11-0.35]). Instituting the intervention did not lengthen checkout duration, which was 15 minutes (95% CI [13.81-16.19]) pre-intervention and 14 minutes (95% CI [12.99-15.01]) post-intervention. The majority of participants (73.4%) felt that the process decreased MCI, and 89.5% reported that the new process had a positive or neutral effect on their satisfaction with care transitions. Conclusion: The adoption of a standardized care transition process markedly decreased clinically relevant communication errors without lengthening checkout duration. [

Research paper thumbnail of Remembering the Health Outcomes of Hurricane Katrina A Decade Later: A Report on Katrina Evacuees Discharged Post ‘Emergent’ Care in a Houston-based Emergency Department

Emergency Medicine - Open Journal, 2015

Research paper thumbnail of Health care utilization of resettled hurricane Katrina victims displaced to a neighboring city

Research paper thumbnail of Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

Emergency Medicine Journal, 2015

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensive... more Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED.

Research paper thumbnail of Using turf to understand the functions of interruptions

AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 2014

Interruptions are an often lamented and frequently studied aspect of clinical practice. However, ... more Interruptions are an often lamented and frequently studied aspect of clinical practice. However, some interruptions, such as updates on patient care decisions and notifications of detrimental patient lab values, are in fact necessary to the work process. In this paper, we explore the interruptions as an emergent feature of communication in teams. Looking beyond the frequency of interruptions, we consider the source and intent of interruptions with the goal of discovering the functions served by such communications. Furthermore, in this study of an emergency department, we classify interruptions into those activities that support required work and those interruptions that create unnecessary breaks in workflow. The intent of our larger body of work is to develop health information technology systems that support team efforts including the functions currently served by interruptions.

Research paper thumbnail of Opportunistic decision making and complexity in emergency care

In critical care environments such as the emergency department (ED), many activities and decision... more In critical care environments such as the emergency department (ED), many activities and decisions are not planned. In this study, we developed a new methodology for systematically studying what are these unplanned activities and decisions. This methodology expands the traditional naturalistic decision making (NDM) frameworks by explicitly identifying the role of environmental factors in decision making. We focused on decisions made by ED physicians as they transitioned between tasks. Through ethnographic data collection, we developed a taxonomy of decision types. The empirical data provide important insight to the complexity of the ED environment by highlighting adaptive behavior in this intricate milieu. Our results show that half of decisions in the ED we studied are not planned, rather decisions are opportunistic decision (34%) or influenced by interruptions or distractions (21%). What impacts these unplanned decisions have on the quality, safety, and efficiency in the ED environment are important research topics for future investigation.

Research paper thumbnail of Opportunistic decision making and complexity in emergency care

Journal of Biomedical Informatics, 2011

In critical care environments such as the emergency department (ED), many activities and decision... more In critical care environments such as the emergency department (ED), many activities and decisions are not planned. In this study, we developed a new methodology for systematically studying what are these unplanned activities and decisions. This methodology expands the traditional naturalistic decision making (NDM) frameworks by explicitly identifying the role of environmental factors in decision making. We focused on decisions made by ED physicians as they transitioned between tasks. Through ethnographic data collection, we developed a taxonomy of decision types. The empirical data provide important insight to the complexity of the ED environment by highlighting adaptive behavior in this intricate milieu. Our results show that half of decisions in the ED we studied are not planned, rather decisions are opportunistic decision (34%) or influenced by interruptions or distractions (21%). What impacts these unplanned decisions have on the quality, safety, and efficiency in the ED environment are important research topics for future investigation.

Research paper thumbnail of Printer Alarm for Notification of Time-Sensitive Results

Annals of Emergency Medicine, 2013

Research paper thumbnail of 432: Comparison of the Health Care Utilization of Resettled Hurricane Katrina Victims

Annals of Emergency Medicine, 2009

Research paper thumbnail of Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department

Western Journal of Emergency Medicine, 2015

Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remedi... more Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system.

Research paper thumbnail of Dashboard Visualizations: Supporting Real-Time Throughput Decision-Making

Journal of biomedical informatics, Jul 1, 2017

Providing timely and effective care in the emergency department (ED) requires the management of i... more Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizatio...

Research paper thumbnail of Improved Accuracy and Quality of Information During Emergency Department Care Transitions

The western journal of emergency medicine, 2017

Suboptimal communication during emergency department (ED) care transitions has been shown to cont... more Suboptimal communication during emergency department (ED) care transitions has been shown to contribute to medical errors, sometimes resulting in patient injury and litigation. The study objective was to determine whether a standardized checkout process would decrease the number of relevant missed clinical items (MCI). In this prospective pre- and post-intervention study conducted in an urban academic ED, we collected data on omitted or inaccurately conveyed medical information before and after the initiation of a standardized checkout process. The intervention included group checkout in an optimal location, review of electronic medical records, case discussion and assigned roles. MCI were considered relevant if they resulted in a delay or alteration in disposition or treatment plan. The primary outcome was the change in the number of MCI. Secondary outcomes were duration of checkout and physician satisfaction with the intervention. Pre-intervention, there were 94 relevant MCI durin...

Research paper thumbnail of Improved Accuracy and Quality of Information During Emergency Department Care Transitions

Western Journal of Emergency Medicine

Introduction: Suboptimal communication during emergency department (ED) care transitions has been... more Introduction: Suboptimal communication during emergency department (ED) care transitions has been shown to contribute to medical errors, sometimes resulting in patient injury and litigation. The study objective was to determine whether a standardized checkout process would decrease the number of relevant missed clinical items (MCI). Methods: In this prospective pre-and post-intervention study conducted in an urban academic ED, we collected data on omitted or inaccurately conveyed medical information before and after the initiation of a standardized checkout process. The intervention included group checkout in an optimal location, review of electronic medical records, case discussion and assigned roles. MCI were considered relevant if they resulted in a delay or alteration in disposition or treatment plan. The primary outcome was the change in the number of MCI. Secondary outcomes were duration of checkout and physician satisfaction with the intervention. Results: Pre-intervention, there were 94 relevant MCI during 164 care transitions. Post-intervention, there were 36 MCI in 157 transitions. The mean MCI per transition decreased by 58% from 0.57 (95% confidence interval [CI] [0.41, 0.73]) to 0.23 (95% CI [0.11-0.35]). Instituting the intervention did not lengthen checkout duration, which was 15 minutes (95% CI [13.81-16.19]) pre-intervention and 14 minutes (95% CI [12.99-15.01]) post-intervention. The majority of participants (73.4%) felt that the process decreased MCI, and 89.5% reported that the new process had a positive or neutral effect on their satisfaction with care transitions. Conclusion: The adoption of a standardized care transition process markedly decreased clinically relevant communication errors without lengthening checkout duration. [

Research paper thumbnail of Remembering the Health Outcomes of Hurricane Katrina A Decade Later: A Report on Katrina Evacuees Discharged Post ‘Emergent’ Care in a Houston-based Emergency Department

Emergency Medicine - Open Journal, 2015

Research paper thumbnail of Health care utilization of resettled hurricane Katrina victims displaced to a neighboring city

Research paper thumbnail of Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

Emergency Medicine Journal, 2015

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensive... more Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED.

Research paper thumbnail of Using turf to understand the functions of interruptions

AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 2014

Interruptions are an often lamented and frequently studied aspect of clinical practice. However, ... more Interruptions are an often lamented and frequently studied aspect of clinical practice. However, some interruptions, such as updates on patient care decisions and notifications of detrimental patient lab values, are in fact necessary to the work process. In this paper, we explore the interruptions as an emergent feature of communication in teams. Looking beyond the frequency of interruptions, we consider the source and intent of interruptions with the goal of discovering the functions served by such communications. Furthermore, in this study of an emergency department, we classify interruptions into those activities that support required work and those interruptions that create unnecessary breaks in workflow. The intent of our larger body of work is to develop health information technology systems that support team efforts including the functions currently served by interruptions.

Research paper thumbnail of Opportunistic decision making and complexity in emergency care

In critical care environments such as the emergency department (ED), many activities and decision... more In critical care environments such as the emergency department (ED), many activities and decisions are not planned. In this study, we developed a new methodology for systematically studying what are these unplanned activities and decisions. This methodology expands the traditional naturalistic decision making (NDM) frameworks by explicitly identifying the role of environmental factors in decision making. We focused on decisions made by ED physicians as they transitioned between tasks. Through ethnographic data collection, we developed a taxonomy of decision types. The empirical data provide important insight to the complexity of the ED environment by highlighting adaptive behavior in this intricate milieu. Our results show that half of decisions in the ED we studied are not planned, rather decisions are opportunistic decision (34%) or influenced by interruptions or distractions (21%). What impacts these unplanned decisions have on the quality, safety, and efficiency in the ED environment are important research topics for future investigation.

Research paper thumbnail of Opportunistic decision making and complexity in emergency care

Journal of Biomedical Informatics, 2011

In critical care environments such as the emergency department (ED), many activities and decision... more In critical care environments such as the emergency department (ED), many activities and decisions are not planned. In this study, we developed a new methodology for systematically studying what are these unplanned activities and decisions. This methodology expands the traditional naturalistic decision making (NDM) frameworks by explicitly identifying the role of environmental factors in decision making. We focused on decisions made by ED physicians as they transitioned between tasks. Through ethnographic data collection, we developed a taxonomy of decision types. The empirical data provide important insight to the complexity of the ED environment by highlighting adaptive behavior in this intricate milieu. Our results show that half of decisions in the ED we studied are not planned, rather decisions are opportunistic decision (34%) or influenced by interruptions or distractions (21%). What impacts these unplanned decisions have on the quality, safety, and efficiency in the ED environment are important research topics for future investigation.

Research paper thumbnail of Printer Alarm for Notification of Time-Sensitive Results

Annals of Emergency Medicine, 2013

Research paper thumbnail of 432: Comparison of the Health Care Utilization of Resettled Hurricane Katrina Victims

Annals of Emergency Medicine, 2009

Research paper thumbnail of Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department

Western Journal of Emergency Medicine, 2015

Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remedi... more Medical errors are frequently under-reported, yet their appropriate analysis, coupled with remediation, is essential for continuous quality improvement. The emergency department (ED) is recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design and implementation of a web-based ED-specific incident reporting system using an iterative process. A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. The utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers reported 24% and 16% respectively. The most commonly reported incidents were delays in care and management concerns. Error reporting frequency can be dramatically improved by using a web-based, user-friendly, voluntary, and non-punitive reporting system.