Emergency Physician Use of the Alberta Netcare Portal, a Province-Wide Interoperable Electronic Health Record: Multi-Method Observational Study.

BACKGROUND: The adoption and use of an electronic health record (EHR) can facilitate real-time access to key health information and support improved outcomes. Many Canadian provinces use interoperable EHRs (iEHRs) to facilitate health information exchange, but the clinical use and utility of iEHRs has not been well described. OBJECTIVE: The aim of this study was to describe the use of a provincial iEHR known as the Alberta Netcare Portal (ANP) in 4 urban Alberta emergency departments. The secondary objectives were to characterize the time spent using the respective electronic tools and identify the aspects that were perceived as most useful by emergency department physicians. METHODS: In this study, we have included 4 emergency departments, 2 using paper-based ordering (University of Alberta Hospital [UAH] and Grey Nuns Community Hospital [GNCH]) and 2 using a commercial vendor clinical information system (Peter Lougheed Centre [PLC] and Foothills Medical Centre [FMC]). Structured clinical observations of ANP use and system audit logs analysis were compared at the 4 sites from October 2014 to March 2016. RESULTS: Observers followed 142 physicians for a total of 566 hours over 376 occasions. The median percentage of observed time spent using ANP was 8.5% at UAH (interquartile range, IQR, 3.7%-13.3%), 4.4% at GNCH (IQR 2.4%-4.4%), 4.6% at FMC (IQR 2.4%-7.6%), and 5.1% at PLC (IQR 3.0%-7.7%). By combining administrative and access audit data, the median number of ANP screens (ie, results and reports displayed on a screen) accessed per patient visit were 20 at UAH (IQR 6-67), 9 at GNCH (IQR 4-29), 7 at FMC (IQR 2-18), and 5 at PLC (IQR 2-14). When compared with the structured clinical observations, the statistical analysis of screen access data showed that ANP was used more at UAH than the other sites. CONCLUSIONS: This study shows that the iEHR is well utilized at the 4 sites studied, and the usage patterns implied clinical value. Use of the ANP was highest in a paper-based academic center and lower in the centers using a commercial emergency department clinical information system. More study about the clinical impacts of using iEHRs in the Canadian context including longer term impacts on quality of practice and safety are required.

Nursing duties and accreditation standards and their impacts: The nursing perspective.

BACKGROUND: Medical advances and increasingly complex patients presenting to the Emergency Department (ED) make nursing challenging. Gaining new knowledge and skills is a perpetual requirement. New quality initiatives to improve patient safety and care are being constantly introduced and create significant work and time pressures for healthcare providers involved. STUDY QUESTION: Do ED nurses support the introduction of new quality standards, in addition to their current heavy workload? STUDY DESIGN: A cross-sectional survey. METHODS: All ED nurses in the Edmonton zone were invited to complete a survey on nursing beliefs regarding various accreditation standards and their impacts. The survey was developed iteratively, involving study investigators, the Health Authority Management Team, and Nursing Managers. Response options included a 7-point Likert scale of agreement. Median ratings and interquartile ranges were determined for each survey statement. RESULTS: A total of 433/1241 (34.9%) surveys were completed. Respondents were RNs (91.4%), female (88.9%), with 0-5years ED experience (43.7%). Overall, respondents 'agreed' or 'strongly agreed' with the statements, indicating favourable attitudes towards Accreditation Canada standards and other quality initiatives. They were neutral towards universal domestic violence screening, and the differentiation between a Best Possible Medication History and medication reconciliation. CONCLUSIONS: Despite their heavy workload, nurses strongly agreed on the importance of medication reconciliation, falls risk, and skin care, but felt that improved documentation forms could support efficiency. This nursing perspective is valuable in informing attempts to standardize and simplify documentation, including the design and implementation of a provincial clinical information system.

Factors influencing time to computed tomography in emergency department patients with suspected subarachnoid haemorrhage.

BACKGROUND: CT has excellent sensitivity for subarachnoid haemorrhage (SAH) when performed within 6 hours of headache onset, but it is unknown to what extent patients with more severe disease are likely to undergo earlier CT, potentially inflating estimates of sensitivity. Our objective was to evaluate which patient and hospital factors were associated with earlier neuroimaging in alert, neurologically intact ED patients with suspected SAH. METHODS: We analysed data from two large sequential prospective cohorts of ED patients with acute headache undergoing CT for suspected SAH. We examined the time interval from headache onset to CT, both overall and subdivided from headache onset to hospital registration and from registration to CT. RESULTS: Among 2412 patients with headache, 194 had SAH, with 178 identified on unenhanced CT. Of these, 91 (51.1%) were identified by CT within 6 hours of headache onset and 87 after 6 hours. Patients with SAH had a shorter time from headache onset to hospital presentation (median 4.5 hours, IQR 1.7-22.7 vs 9.6 hours, IQR 2.8-46.0, p<0.001) and were imaged sooner after headache onset (6.4 hours, IQR 3.5-27.1 vs 12.6 hours, IQR 5.5-48.0, p<0.001) compared with those without SAH. The median time from in-hospital registration to CT scan was significantly shorter in those patients with SAH although this difference was less than 1 hour (1.9 hours, IQR 1.2-2.8 vs 2.5 hours, IQR 1.5-3.9, p<0.001). Arrival by ambulance (OR 3.1, 95% CI 1.94 to 4.98, p<0.001) and higher acuity at triage (OR 1.39, 95% CI 1.02 to 1.88, p=0.032) were among the factors associated with having CT imaging within 6 hours of headache onset. CONCLUSIONS: Time from headache onset to imaging is moderately associated with positive imaging for SAH. Delay to hospital presentation accounts for the largest fraction of time to imaging, especially those without SAH. These findings suggest limited opportunity to reduce lumbar puncture rates simply by accelerating in-hospital processes when imaging delays are under 2 hours, as diagnostic yield of imaging decreases beyond the 6-hour imaging window from headache onset.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study.

OBJECTIVES: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture. DESIGN: A substudy of a prospective multicenter cohort study. SETTING: 12 Canadian academic emergency departments, from November 2000 to December 2009. PARTICIPANTS: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage. MAIN OUTCOME MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death. RESULTS: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%). CONCLUSION: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

Clinical decision rules to rule out subarachnoid hemorrhage for acute headache.

IMPORTANCE: Three clinical decision rules were previously derived to identify patients with headache requiring investigations to rule out subarachnoid hemorrhage. OBJECTIVE: To assess the accuracy, reliability, acceptability, and potential refinement (ie, to improve sensitivity or specificity) of these rules in a new cohort of patients with headache. DESIGN, SETTING, AND PATIENTS: Multicenter cohort study conducted at 10 university-affiliated Canadian tertiary care emergency departments from April 2006 to July 2010. Enrolled patients were 2131 adults with a headache peaking within 1 hour and no neurologic deficits. Physicians completed data forms after assessing eligible patients prior to investigations. MAIN OUTCOMES AND MEASURES: Subarachnoid hemorrhage, defined as (1) subarachnoid blood on computed tomography scan; (2) xanthochromia in cerebrospinal fluid; or (3) red blood cells in the final tube of cerebrospinal fluid, with positive angiography findings. RESULTS: Of the 2131 enrolled patients, 132 (6.2%) had subarachnoid hemorrhage. The decision rule including any of age 40 years or older, neck pain or stiffness, witnessed loss of consciousness, or onset during exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%) specificity for subarachnoid hemorrhage. Adding "thunderclap headache" (ie, instantly peaking pain) and "limited neck flexion on examination" resulted in the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3% (95% CI, 13.8%-16.9%) specificity. CONCLUSIONS AND RELEVANCE: Among patients presenting to the emergency department with acute nontraumatic headache that reached maximal intensity within 1 hour and who had normal neurologic examination findings, the Ottawa SAH Rule was highly sensitive for identifying subarachnoid hemorrhage. These findings apply only to patients with these specific clinical characteristics and require additional evaluation in implementation studies before the rule is applied in routine clinical care.

Pilot study comparing sepsis management with and without electronic clinical practice guidelines in an academic emergency department.

BACKGROUND: Sepsis is a potentially life-threatening condition that requires urgent management in an Emergency Department (ED). Evidence-based guidelines for managing sepsis have been developed; however, their integration into routine practice is often incomplete. Care maps may help clinicians meet guideline targets more often. OBJECTIVES: To determine if electronic clinical practice guidelines (eCPGs) improve management of patients with severe sepsis and septic shock (SS/SS). METHODS: The impact of an eCPG on the management of patients presenting with SS/SS over a 3-year period at a tertiary care ED was evaluated using retrospective case-control design and chart review methods. Cases and controls, matched by age and sex, were chosen from an electronic database using physician sepsis diagnoses. Data were compared using McNemar tests or paired t-tests, as appropriate. RESULTS: Overall, 51 cases and controls were evaluated; the average age was 62 years, and 60% were male. eCPG patients were more likely to have a central venous pressure and central venous oxygen saturation measured; however, lactate measurement, blood cultures, and other investigations were similarly ordered (all p > 0.05). The administration of antibiotics within 3 h (63% vs. 41%; p = 0.03) and vasopressors (45% vs. 20%; p = 0.02) was more common in the eCPG group; however, use of corticosteroids and other interventions did not differ between the groups. Overall, survival was high and similar between groups. CONCLUSION: A sepsis eCPG experienced variable use; however, physicians using the eCPG achieved more quality-of-care targets for SS/SS. Strategies to increase the utilization of eCPGs in Emergency Medicine seem warranted.

The role of full capacity protocols on mitigating overcrowding in EDs.

OBJECTIVE: Overcrowding is an important issue facing many emergency departments (EDs). Access block (admitted patients occupying ED stretchers) is a leading contributor, and expeditious placement of admitted patients is an area of research interest. This review examined the effectiveness of full capacity protocols (FCPs) on mitigating ED overcrowding. METHODS: A comprehensive literature search was undertaken to identify potentially relevant studies between 1966 and 2009. Intervention studies in which an FCP was used to influence ED/hospital length of stay and ED/hospital access block were included as a single program or part of a systemwide intervention. Two reviewers independently assessed citation relevance, inclusion, study quality, and extracted data; because of limited data, pooling was not undertaken. RESULTS: From 14 446 potentially relevant studies, 2 abstracts from the same comparative study were included. From 29 studies on systemwide intervention, 4 contained an FCP component. The included study was a single-center ED study using a before-after design; its methodological quality was rated as weak. One of the abstracts reported that an FCP was associated with less ED length of stay (5-hour reduction) when compared with the comparison period; the other reported that an FCP decreased ED and hospital access block (28% and 37% reduction, respectively). The ED triggers, format, and implementation of FCP protocols varied widely. CONCLUSION: Although FCPs may be a promising alternative for overcrowded EDs, the available evidence upon which to support implementation of an FCP is limited. Additional efforts are required to improve the outcome reporting of FCP research using high-quality research methods.

Febrile neutropenia in EDs: the role of an electronic clinical practice guideline.

PURPOSE: Evidence-based clinical practice guidelines (CPGs) for managing febrile neutropenia (FN) are widely available; however, the integration of guidelines into routine practice is often incomplete. This study evaluated the uptake and clinical impact of implementing an electronic CPG on the management and outcomes of patients presenting with FN at 4 urban emergency departments (ED). METHODS: A retrospective chart review over a 3-year period at 4 hospitals in Edmonton, Alberta, was performed. Potentially eligible patient visits were identified by searching the Ambulatory Care Classification System database using International Classification of Diseases, 10th Edition, codes and ED physician diagnoses of FN. ED patients with fever (>38°C at home or in ED) and neutropenia (white blood cell count of <1000 cells/mm(3) or a neutrophil count of <500 cells/mm(3)) who received an ED diagnosis of FN were included. RESULTS: From 371 potential cases, 201 unique cases of FN were included. Overall, the electronic CPG was used in 76 (37.8%) of 201 patient visits; however, there were significant differences in CPG utilization between hospitals. Clinical practice guideline usage was greatest at the University of Alberta Hospital (57%). This finding correlated with a decrease in time from triage to first antibiotic by 1 hour compared to the 3 control hospitals (3.9 vs 4.9 hours, P = .022). CONCLUSIONS: The electronic CPG is a useful clinical tool that can improve patient management in the ED, and strategies to increase its utilization in this and other regions should be pursued.

The role of a rapid assessment zone/pod on reducing overcrowding in emergency departments: a systematic review.

OBJECTIVE: To evaluate the effectiveness of a rapid assessment zone (RAZ) to mitigate emergency department (ED) overcrowding. METHODS: Electronic databases, controlled trial registries, conference proceedings, study references, experts in the field and correspondence with authors were used to identify potentially relevant studies. Intervention studies, in which a RAZ was used to influence length of stay, physician initial assessment and patients left without being seen, were included. Mean differences were calculated and reported with corresponding 95% CIs; individual statistics are presented as RR with associated 95% CI. RESULTS: From 14 446 potentially relevant studies, four studies were included in the review. The quality of one study was appraised as moderately high; others were rated as weak. Two studies showed that a RAZ was associated with a reduction of 20 min (95% CI: -47.2 to 7.2) in the ED length of stay; in one non-randomised clinical trial (RCT), a 192 min reduction was reported (95% CI: -211.6 to -172.4). Physician initial assessment showed a reduction of 8.0 min; 95% CI: -13.8 to -2.2 in the RCT and a reduction of 33 min (95% CI: -42.3 to -23.6) and 18 min (95% CI: -22.2 to -13.8) respectively were found in two non-RCTs. There was a reduction in the risk of patient leaving without being seen (RCT: RR=0.93, 95% CI: 0.77 to 1.12; non-RCT: RR =0.68, 95% CI: 0.63 to 0.73). CONCLUSIONS: Although the results are consistent, and low acuity patients seem to benefit the most from a RAZ, the available evidence to support its implementation is limited.

Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.

OBJECTIVE: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. DESIGN: Prospective cohort study. SETTING: 11 tertiary care emergency departments across Canada, 2000-9. PARTICIPANTS: Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. MAIN OUTCOME MEASURES: Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. RESULTS: Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). CONCLUSION: Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review.

OBJECTIVES: The objective was to examine the effectiveness of triage nurse ordering (TNO) on mitigating the effect of emergency department (ED) overcrowding. METHODS: Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, HealthSTAR, Dissertation Abstracts, ABI/INFORM Global), controlled trial registry websites, conference proceedings, study references, experts in the field, and correspondence with authors were used to identify potentially relevant studies. Interventional studies in which TNO was used to influence ED overcrowding metrics (length of stay [LOS] and physician initial assessment [PIA]) were included in the review. Two reviewers independently assessed study eligibility and methodologic quality. Mean differences were calculated and reported with corresponding 95% confidence intervals (CIs). RESULTS: From more than 14,000 potentially relevant studies, 14 were included in the systematic review. Most were single-center ED studies; the overall quality was rated as weak, due to methodologic deficiencies and variable outcome reporting. TNO was associated with a 37-minute mean reduction (95% CI = -44.10 to -30.30 minutes) in the overall ED LOS in one randomized clinical trial (RCT); a 51-minute mean reduction (95% CI = -56.3 to -45.5 minutes) was observed in non-RCTs. When applied to injured subjects with suspected fractures, TNO interventions reduced ED LOS by 20 minutes (95% CI = -37.5 to -1.9 minutes) in three RCTs and by 18 minutes (95% CI = -23.2 to -13.2) in two non-RCTs. No significant reduction in PIA was observed in two RCTs. CONCLUSIONS: Overall, TNO appears to be an effective intervention to reduce ED LOS, especially in injury and/or suspected fracture cases. The available evidence is limited by small numbers of studies, weak methodologic quality, and incomplete reporting. Future studies should focus on a better description of the contextual factors surrounding these interventions and exploring the impact of TNO on other indicators of productivity and satisfaction with health care delivery.

Comparison between Canadian Triage and Acuity Scale and Taiwan Triage System in emergency departments.

BACKGROUND/PURPOSE: Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients. METHODS: This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels. RESULTS: There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS. CONCLUSION: CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization.

High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study.

OBJECTIVE: To identify high risk clinical characteristics for subarachnoid haemorrhage in neurologically intact patients with headache. DESIGN: Multicentre prospective cohort study over five years. SETTING: Six university affiliated tertiary care teaching hospitals in Canada. Data collected from November 2000 until November 2005. PARTICIPANTS: Neurologically intact adults with a non-traumatic headache peaking within an hour. MAIN OUTCOME MEASURES: Subarachnoid haemorrhage, as defined by any of subarachnoid haemorrhage on computed tomography of the head, xanthochromia in the cerebrospinal fluid, or red blood cells in the final sample of cerebrospinal fluid with positive results on angiography. Physicians completed data collection forms before investigations. RESULTS: In the 1999 patients enrolled there were 130 cases of subarachnoid haemorrhage. Mean (range) age was 43.4 (16-93), 1207 (60.4%) were women, and 1546 (78.5%) reported that it was the worst headache of their life. Thirteen of the variables collected on history and three on examination were reliable and associated with subarachnoid haemorrhage. We used recursive partitioning with different combinations of these variables to create three clinical decisions rules. All had 100% (95% confidence interval 97.1% to 100.0%) sensitivity with specificities from 28.4% to 38.8%. Use of any one of these rules would have lowered rates of investigation (computed tomography, lumbar puncture, or both) from the current 82.9% to between 63.7% and 73.5%. CONCLUSION: Clinical characteristics can be predictive for subarachnoid haemorrhage. Practical and sensitive clinical decision rules can be used in patients with a headache peaking within an hour. Further study of these proposed decision rules, including prospective validation, could allow clinicians to be more selective and accurate when investigating patients with headache.

Delphi consensus on the feasibility of translating the ACEP clinical policies into computerized clinical decision support.

Clinical practice guidelines are developed to reduce variations in clinical practice, with the goal of improving health care quality and cost. However, evidence-based practice guidelines face barriers to dissemination, implementation, usability, integration into practice, and use. The American College of Emergency Physicians (ACEP) clinical policies have been shown to be safe and effective and are even cited by other specialties. In spite of the benefits of the ACEP clinical policies, implementation of these clinical practice guidelines into physician practice continues to be a challenge. Translation of the ACEP clinical policies into real-time computerized clinical decision support systems could help address these barriers and improve clinician decision making at the point of care. The investigators convened an emergency medicine informatics expert panel and used a Delphi consensus process to assess the feasibility of translating the current ACEP clinical policies into clinical decision support content. This resulting consensus document will serve to identify limitations to implementation of the existing ACEP Clinical Policies so that future clinical practice guideline development will consider implementation into clinical decision support at all stages of guideline development.

Tracking emergency department overcrowding in a tertiary care academic institution.

Despite the release of a national report describing key markers of emergency department (ED) overcrowding, limited linear data using these markers have been published. We sought to report the degree and trends of ED overcrowding in a typical academic hospital and to highlight some of the key markers of ED patient flow and care. We conducted a prospective study in a large Canadian urban tertiary care teaching hospital that receives approximately 55,000 annual adult ED visits. A database captured demographic and real-time process of care data for each patient from 2000 to 2007. Descriptive data are reported using Canadian Triage and Acuity Scale (CTAS) scores. Over the study period, the ED patient visit volume and presentation times remained predictable. Emergent cases (CTAS levels 1-2) doubled from 8 to 16.6%, and urgent cases (CTAS level 3) increased from 40.2 to 50.3%. Moreover, semi-urgent presentations (CTAS level 4) decreased from 42.4 to 28.8%, and non-urgent cases (CTAS level 5) dropped from 9.4 to 4.3%. The median wait time from triage to bed location increased from two minutes (inter-quartile range [IQR] 1, 46) in 2000 to 27 minutes (IQR 2, 110) in 2007, while the median time from bed location to physician remained constant (29 minutes in 2001 versus 28 minutes in 2007). Overall, admissions increased from 20.4 to 23%. Semi-urgent and non-urgent admissions dropped from 11.5 to 7.4% and 3.2 to 1.8%, respectively. Admitted patients "boarding" in the ED increased from 70,955 hours in 2002 to 118,741 hours in 2007, while the number of emergent and urgent patients leaving without being seen increased by more than 400%. ED overcrowding in a tertiary care hospital is primarily a result of access block due to boarding admitted patients, a situation that poses serious risks to the majority of patients who have emergent or urgent conditions that cannot be managed appropriately in the waiting room.

How usability of a web-based clinical decision support system has the potential to contribute to adverse medical events.

INTRODUCTION: Clinical decision support systems (CDSS) have the potential to reduce adverse medical events, but improper design can introduce new forms of error. CDSS pertaining to community acquired pneumonia and neutropenic fever were studied to determine whether usability of the graphical user interface might contribute to potential adverse medical events. METHODS: Automated screen capture of 4 CDSS being used by volunteer emergency physicians was analyzed using structured methods. RESULTS: 422 events were recorded over 56 sessions. In total, 169 negative comments, 55 positive comments, 130 neutral comments, 21 application events, 34 problems, 6 slips, and 5 mistakes were identified. Three mistakes could have had life-threatening consequences. CONCLUSION: Evaluation of CDSS will be of utmost importance in the future with increasing use of electronic health records. Usability engineering principles can identify interface problems that may lead to potential medical adverse events, and should be incorporated early in the software design phase.