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Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit journals.sagepub.com/eprint/DvjxAnW… HIStalk @UTHealth_SBMI Eric Thomas

Couldn’t ask for a better wife and friend as well! x.com/hardeepsinghmd…

To accelerate progress in reducing preventable harm from diagnostic errors we propose a new ‘Safer Dx Trigger Tools Framework’ BMJ Quality & Safety #improvedx #patientsafety #EHR #healthIT qualitysafety.bmj.com/content/early/…

Getting to high reliability - Preoccupation with failure and adherence to shared baselines. Need to implement across NICUs CPQCC ⁦Stanford Neonatology⁩ ⁦Stanford Children's⁩ journals.sagepub.com/doi/full/10.11…

The harms of promoting ‘Zero Harm’ qualitysafety.bmj.com/content/early/… UTHealth_SBMI @UTHealth HIStalk @ECRI_Institute

Terrific piece in NEJM by Leora Horwitz showing substantive improvements (and learning about changes that didn’t work out) balancing rigour and pragmatism - a great example for health system leaders and for researchers in quality improvement nejm.org/doi/full/10.10…

Our new narrative review led by gshafer on diagnostic errors in the neonatal intensive care unit sciencedirect.com/science/articl… Should help future focus in #NICU #neonatology #patientsafety cc IQuESt Jochen Profit Jennifer Arnold, MD Eric Thomas

Happy to see this in print and to have gotten to work with brilliant, resilient co-authors Daniel Tawfik Jochen Profit Eric Thomas and all the rest whose Twitter handles I don’t have😄

We’ve drawn upon the growing body of research on #teameffectiveness to offer evidence-based advice for healthcare teams. We hope the tips are of assistance during/after the pandemic. In BMJ Quality & Safety with Allison Traylor, Eric Thomas, Eduardo Salas qualitysafety.bmj.com/content/early/…

What factors does BMJ Quality & Safety consider when deciding if a research question is important?

Are you interested in joining the BMJ Quality & Safety editorial team? Applications are now open for Quality and Safety in the Literature (QSL) Editors. Find out more about the position here 👉 bit.ly/3VJuJSi Applications close January 15th. Bryony Dean Franklin Eric Thomas

To change unspecified anemia on problem list to iron deficiency I clicked “refine problem” and was given 75 options, none were iron deficiency and only one or two that I’d ever use. No option to create favorites list, had to search for new problem. #FunctioningAsDesigned

To be fair #FunctioningAsDesigned EHR is good too. Saw diabetic with HTN not on ACEI or ARB. In 60 sec EHR allowed us to identify date in 2010 when it was stopped after acute renal failure. Now should be back on it. Would be longer or impossible to figure out with paper chart.

#FunctioningAsDesigned After checking the spelling of the last name 2x on admission, then again as the tech applied the Patient-ID wristband, we realized that the last name field is limited to 12 characters AND they auto-deleted the hyphen between names. EHR Safety violations!

Fear of no change, retaliation, and negative feedback prevent health care professionals from speaking up about #PatientSafety concerns. Our (w/ Eric Thomas Jørgen Ottosen) latest study: rand.org/pubs/external_… /1

We also found higher perceptions of safety culture and teamwork culture in those who feel comfortable speaking up. /2

In UK, 450,000 patients missed breast cancer screening due to “computer algorithm failure” Major IT error found on an IT system upgrade. Took a decade for discovery. theguardian.com/society/2018/m…

Article in JAHA by Emory Cardiology reporting only 17% of cases identified through #EHR query as statin prescription failures were actually failures. EHR #FunctioningAsDesigned - not designed to measure quality. ncbi.nlm.nih.gov/pubmed/29650707

Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? ie, our outdated regulatory requirements. annals.org/article.aspx?a… @calonghurst David Bates @ONC_HealthIT

Adherence to recommended electronic health record safety practices across eight health care organizations AHRQ psnet.ahrq.gov/resources/reso…