title: Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system.
abstract: BACKGROUND
  "Meaningful use" of electronic health records to improve quality of care has remained understudied. We evaluated an approach to improving patients' safety and quality of care involving the secondary use of data from a hospital electronic prescribing and decision support system (ePDSS).
  
  
  METHODS
  We conducted a case study of a large English acute care hospital with a well-established ePDSS. Our study was based on ethnographic observations of clinical settings (162 hours) and meetings (28 hours), informal conversations with clinical staff, semistructured interviews with ten senior executives, and the collection of relevant documents. Our data analysis was based on the constant comparative method.
  
  
  RESULTS
  This hospital's approach to quality and safety could be characterized as "technovigilance." It involved treating the ePDSS as a warehouse of data on clinical activity and performance. The hospital converted the secondary data into intelligence about the performance of individuals, teams, and clinical services and used this as the basis of action for improvement. Through a combination of rapid audit, feedback to clinical teams, detailed and critical review of apparent omissions in executive-led meetings, a focus on personal professional responsibility for patients' safety and quality care, and the correction of organizational or systems defects, technovigilance was-based on the hospital's own evidence-highly effective in improving specific indicators. Measures such as the rate of omitted doses of medication showed marked improvement. As do most interventions, however, technovigilance also had unintended consequences. These included the risk of focusing attention on aspects of patient safety made visible by the system at the expense of other, less measurable but nonetheless important, concerns.
  
  
  CONCLUSIONS
  The secondary use of electronic data can be effective for improving specific indicators of care if accompanied by a range of interventions to ensure proper interpretation and appropriate action. But care is needed to avoid unintended consequences.
authors.affiliation: University of Leicester.
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Sabi
authors.initials: S
authors.lastname: Redwood
authors.forename: Myles
authors.initials: M
authors.lastname: Leslie
authors.forename: Joel
authors.initials: J
authors.lastname: Minion
authors.forename: Graham P
authors.initials: GP
authors.lastname: Martin
authors.forename: Jamie J
authors.initials: JJ
authors.lastname: Coleman
mesh_terms: D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D004739:England; D005246:Feedback; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control; D009936:Organizational Innovation; D061214:Patient Safety; D011643:Publishing; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D013222:State Medicine
keywords: electronic health records; ethnography; meaningful use; medication errors; patient safety; quality of care
references.citation: Jt Comm J Qual Patient Saf. 2011 Nov;37(11):483-93
references.pmid: 22132659
references.citation: BMC Med Inform Decis Mak. 2012 Feb 14;12:6
references.pmid: 22333210
references.citation: Anesth Analg. 2011 Apr;112(4):958-66
references.pmid: 21385976
references.citation: Milbank Q. 2012 Sep;90(3):548-91
references.pmid: 22985281
references.citation: Med Care. 2012 Jul;50 Suppl:S49-59
references.pmid: 22692259
references.citation: N Engl J Med. 2011 Apr 14;364(15):1407-18
references.pmid: 21488763
references.citation: Soc Sci Med. 2009 Aug;69(3):362-9
references.pmid: 19535193
references.citation: Crit Care Med. 2006 Jun;34(6):1589-96
references.pmid: 16625125
references.citation: Sci Transl Med. 2010 Nov 10;2(57):57cm29
references.pmid: 21068440
references.citation: Milbank Q. 2011 Jun;89(2):167-205
references.pmid: 21676020
references.citation: Health Aff (Millwood). 2011 Oct;30(10):2005-12
references.pmid: 21918179
references.citation: N Engl J Med. 2012 Jun 14;366(24):2243-5
references.pmid: 22693996
references.citation: J Am Coll Cardiol. 2005 Apr 5;45(7):1147-56
references.pmid: 15808779
references.citation: J Am Med Inform Assoc. 2012 Jul-Aug;19(4):604-9
references.pmid: 22249967
references.citation: J R Stat Soc Ser A Stat Soc. 2009 Jan;172(1):161-190
references.pmid: 19381327
references.citation: Eur J Public Health. 2013 Feb;23(1):86-92
references.pmid: 22577123
references.citation: Lancet. 2004 Mar 27;363(9414):1061-7
references.pmid: 15051287
references.citation: J Am Med Inform Assoc. 2007 Jan-Feb;14(1):1-9
references.pmid: 17077452
references.citation: Acad Med. 2011 Mar;86(3):314-20
references.pmid: 21248609
references.citation: J Am Med Inform Assoc. 2010 Nov-Dec;17(6):646-51
references.pmid: 20962126
references.citation: Am J Infect Control. 2009 Mar;37(2):85-93
references.pmid: 19249637
references.citation: Milbank Q. 2009 Dec;87(4):729-88
references.pmid: 20021585
references.citation: JAMA. 2007 Oct 17;298(15):1800-2
references.pmid: 17940238
references.citation: N Engl J Med. 2010 Aug 5;363(6):501-4
references.pmid: 20647183
references.citation: Health Care Manage Rev. 2002 Summer;27(3):35-47
references.pmid: 12146782
references.citation: Ann Intern Med. 2013 Jan 15;158(2):77-83
references.pmid: 23318309
references.citation: BMJ Qual Saf. 2012 Nov;21(11):969-72
references.pmid: 23038407
references.citation: Qual Saf Health Care. 2005 Apr;14(2):99-106
references.pmid: 15805454
references.citation: Int J Qual Health Care. 2012 Jun;24(3):200-5
references.pmid: 22490301
references.citation: Drug Saf. 2012 Aug 1;35(8):677-83
references.pmid: 22734657
references.citation: Soc Sci Med. 2009 Dec;69(12):1767-76
references.pmid: 19854551
references.citation: Nurs Crit Care. 2010 May-Jun;15(3):112-7
references.pmid: 20500649
references.citation: Health Aff (Millwood). 2005 Jan-Feb;24(1):138-50
references.pmid: 15647225
references.citation: PLoS Med. 2011 Jan 18;8(1):e1000387
references.pmid: 21267058
references.citation: Mayo Clin Proc. 2007 Jun;82(6):735-9
references.pmid: 17550754
references.citation: BMC Health Serv Res. 2012 Apr 30;12:105
references.pmid: 22545646
references.citation: Med Care Res Rev. 2010 Oct;67(5):503-27
references.pmid: 20150441
references.citation: Qual Saf Health Care. 2004 Feb;13(1):62-6
references.pmid: 14757802
references.citation: Qual Saf Health Care. 2003 Dec;12 Suppl 1:i7-12
references.pmid: 14645741
references.citation: N Engl J Med. 2009 Oct 1;361(14):1401-6
references.pmid: 19797289
references.citation: Qual Saf Health Care. 2004 Feb;13(1):26-31
references.pmid: 14757796
references.citation: Qual Saf Health Care. 2010 Aug;19 Suppl 2:i25-33
references.pmid: 20693213
references.citation: BMC Med. 2011 Apr 27;9:45
references.pmid: 21521535