Automatically Getting Better

Abstract

The Children’s National informatics and technology team built an electronic reporting tool which identifies adverse events occurring throughout their hospital based upon queries of their electronic health record (EHR) system, such as abnormal lab data (e.g. low glucose) or antidote medications prescribed in the event of a medical problem (e.g. Naloxone). This daily report, termed the Automated Adverse Event Detection (AAED), is monitored by a nurse who analyzes each abnormal item to determine its level of harm and whether it was preventable. The appropriate physicians and managers then study this information to determine how they can improve their processes and avoid similar adverse events in the future. The review team may include the clinicians involved with the event as well as “trigger-specific experts” (e.g. hypoglycemia cases are reviewed with endocrinologists, naloxone adverse events are reviewed with pain medicine experts).