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The number of surgeries performed in the United States has increased over the past two decades, with a shift to the ambulatory setting. Perioperative complications and mortality pose significant health care burdens. Inadequate preoperative assessment and documentation contribute to communication failure and poor patient outcomes. The aim of this quality improvement project was to design and implement a preoperative evaluation documentation template that not only improved communication during the perioperative [...]

Observational research has shown its potential to complement experimental research and clinical trials by secondary use of treatment data from hospital care processes. It can also be applied to better understand pediatric drug utilization for establishing safer drug therapy. Clinical documentation processes often limit data quality in pediatric medical records requiring data curation steps, which are mostly underestimated.

Standardized taxonomies (STs) facilitate knowledge representation and semantic interoperability within health care provision and research. However, a gap exists in capturing knowledge representation to classify, quantify, qualify, and codify the intersection of evidence and quality improvement (QI) implementation. This interprofessional case report leverages a novel semantic and ontological approach to bridge this gap.

When administering an infusion to a patient, it is necessary to verify that the infusion pump settings are in accordance with the injection orders provided by the physician. However, the infusion rate entered into the infusion pump by the health care provider cannot be automatically reconciled with the injection order information entered into the electronic medical records (EMRs). This is because of the difficulty in linking the infusion rate entered [...]

The purpose of the Ambulatory Electronic Health Record (EHR) Evaluation Tool is to provide outpatient clinics with an assessment that they can use to measure the ability of the EHR system to detect and prevent common prescriber errors. The tool consists of a medication safety test and a medication reconciliation module.

Clinical Informatics (CI), a medical subspecialty since 2011, has grown from the initial four fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) in 2014 to more than 50 and counting in the present day. In parallel, the literature guiding Clinical Informatics Fellowship training and the curriculum evolved from the original core content published in 2009 to the more recent CI Subspecialty Delineation of Practice and the [...]

Patients and families at risk for health disparities may also be at higher risk for diagnostic errors but less likely to report them.

Social determinants of health (SDoH)a are increasingly recognized as a main contributor to clinical health outcomes, but the technologies and workflows within clinics make it difficult for health care providers to address SDoH needs during routine clinical visits.

Most rheumatic heart disease (RHD) registries are static and centralized, collecting epidemiological and clinical data without providing tools to improve care. We developed a dynamic cloud-based RHD case management application with the goal of improving care for patients with RHD in Uganda.

In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect [...]