text:
Evaluating the Current State of Patient Safety and Health IT
Health IT creates new opportunities to improve patient safety that do not exist in paper-based systems. For example, paper-based systems cannot detect and alert clinicians of drug-drug interactions, whereas electronic clinical decision support systems can. As a result, the expectations for safer care may be higher in a health IT-enabled environment as compared to a paper-based environment. However, implementation of health IT products does not automatically improve patient safety. In fact, health IT can be a contributing factor to adverse events, such as the overdosing of patients because of poor user interface design, failing to detect life threatening illnesses because of unclear information displays, and delays in treatment because of the loss of data. Adverse events, such as these, have lead to serious injuries and death (Aleccia, 2011; Associated Press, 2009; Graham and Dizikes, 2011; Schulte and Schwartz, 2010; Silver and Hamill, 2011; U.S. News, 2011).
The way in which health IT is designed, implemented, and used can determine whether it is an effective tool for improving patient safety or a hindrance that threatens patient safety and causes patient harm (see Box 2-1). The implementation of health IT, particularly complex health IT products, may result in less efficient systems and not give clinicians the flexibility they need to deliver the safest care possible (Greenhalgh et al., 2008). Currently, the relationship between these unintended consequences and the design, implementation, and use are not well understood.
This chapter uses the literature and experiences of health professionals to evaluate the impact of health IT on patient safety. The first several sections of this chapter discuss the challenges faced by health IT researchers by
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Evaluating the Current State of
Patient Safety and Health IT
Health IT creates new opportunities to improve patient safety that do
not exist in paper-based systems. For example, paper-based systems cannot
detect and alert clinicians of drug–drug interactions, whereas electronic
clinical decision support systems can. As a result, the expectations for safer
care may be higher in a health IT–enabled environment as compared to
a paper-based environment. However, implementation of health IT prod-
ucts does not automatically improve patient safety. In fact, health IT can
be a contributing factor to adverse events, such as the overdosing of pa-
tients because of poor user interface design, failing to detect life threatening
illnesses because of unclear information displays, and delays in treatment
because of the loss of data. Adverse events, such as these, have lead to
serious injuries and death (Aleccia, 2011; Associated Press, 2009; Graham
and Dizikes, 2011; Schulte and Schwartz, 2010; Silver and Hamill, 2011;
U.S. News, 2011).
The way in which health IT is designed, implemented, and used can
determine whether it is an effective tool for improving patient safety or
a hindrance that threatens patient safety and causes patient harm (see
Box 2-1). The implementation of health IT, particularly complex health
IT products, may result in less efficient systems and not give clinicians the
flexibility they need to deliver the safest care possible (Greenhalgh et al.,
2008). Currently, the relationship between these unintended consequences
and the design, implementation, and use are not well understood.
This chapter uses the literature and experiences of health professionals
to evaluate the impact of health IT on patient safety. The first several sec-
tions of this chapter discuss the challenges faced by health IT researchers by
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Unintended Consequences of Health IT:
A Look at Implementing CPOE
Two pediatric intensive care units (ICUs) implemented the same elec-
tronic health record (EHR) system with computerized provider order
entry (CPOE) in Pittsburgh and Seattle. The Pittsburgh experience led to
a significant increase in mortality, while the same system implemented in
Seattle did not (Del Beccaro et al., 2006; Han et al., 2005). Later, several
other children's hospitals introduced the same CPOE system, leading to
no change or even lower rates in mortality (Longhurst et al., 2010).
The differing impact on mortality rates may be due to the hospitals'
differences in the implementation and use of the CPOE system. These
differences, as illustrated by the Pittsburgh and Seattle pediatric ICUs,
are highlighted below:
• pecific order sets designed for critical care were not created.
• hanges in workflow were not sufficiently predicted, resulting in a
breakdown of communication between nurses and physicians.
• rders for patients arriving via critical care transportation could not
be written before the patients arrived at the hospital, delaying life-
saving treatments.
• hanges, unrelated to the CPOE system, were made in the administra-
tion and dispensing of medication that further frustrated the clinical
staff, for example:
o At the same time the CPOE system was installed, the satellite phar-
macy serving the neonatal ICU was closed and medications had to
be obtained from the central pharmacy, delaying treatment.
o Emergency prescriptions were required to be preapproved, and all
drugs were moved to the central pharmacy.
• esearchers visited Pittsburgh to learn about problems associated
with their implementation of the CPOE system.
• ntensive care staff was actively involved during the design, build, and
implementation stages.
• pecific order sets were designed for ICU and pediatric ICU before
• ew order sets, based on the most frequently used orders, were cre-
ated to help reduce the time it takes a clinician to enter orders (Del
Beccaro et al., 2006; Han et al., 2005).
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detailing the complexity of health IT and patient safety, the limitations in
the literature to determine health IT's impact on patient safety, and how the
magnitude of harm is masked. The chapter then analyzes the literature to
determine how individual components of health IT have impacted patient
safety and how data from health IT can be leveraged to improve safety in
different populations. Next, it describes how policy makers can learn from
health IT experiences from abroad.
In general, health IT is not a specific product but is composed of
components—such as computerized provider order entry (CPOE) systems
and clinical decision support (CDS) systems—that are designed, imple-
mented, and used differently by various vendors, health care settings, and
users (Hayrinen et al., 2008). These differences can have dramatic effects
on care processes including care design, workflow, and—ultimately—the
quality and safety of the care delivered. When health IT is designed and
implemented in a manner that complements how information is trans-
ferred between health professionals and patients, the reliability of patient
information—and therefore patient safety—can increase (Dorr et al., 2007;
Niazkhani et al., 2009; Shah et al., 2006). However, when health IT un-
expectedly alters workflow, it has the potential to hinder clinicians' abili-
ties to communicate patient information (Niazkhani et al., 2009), and it
may result in increased cognitive workload, clinicians ignoring computer-
generated information, continued reliance on various traditional modes
of communication, creation of unsafe workarounds, and more time spent
dealing with health IT than with patient care (Ash et al., 2009). Several
important factors regarding how health IT products are designed and
implemented can have meaningful effects on the collection, storage, and
transfer of information, as well as the utility of the product. Slight varia-
tions in these factors can have differing effects on how health IT impacts
patient safety. Some of these factors include the following:
• Decisions about implementation strategies (e.g., "big bang" versus
• The degree to which users can configure their IT system and the
approaches to such configurations;
• Clinician training strategies;
• Frontline use (e.g., the IT integration into and redesign of clinical
workflow); and
• Tools for analyzing and reporting results of care (e.g., quality
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Like all studies regarding patient safety, studies focusing on health IT
and patient safety are complex and subject to a variety of methodological
challenges. To provide generalizable knowledge about the impact of health
IT on patient safety, the interaction of the factors listed in the previous sec-
tion (e.g., frontline use) needs to be understood. However, very few studies
to date have done so, resulting in major gaps in our knowledge regarding
how health IT affects safety. While most of the literature examining the
effects of health IT has focused on quality and processes of care, studies
regarding the impact of health IT on patient safety have been narrowly
focused on a few specific aspects of care. Given that adverse events (events
resulting in unintended harm to a patient from a medical intervention
[IOM, 2004]) are multifaceted and diverse, much of the literature that does
center on how health IT affects patient safety has focused on prevention of
medication errors, identification of patients at high risk for adverse events,
and avoidance of documentation errors. Although much of this evidence
suggests that IT can be helpful in improving patient safety, a number of
studies have failed to find a benefit (Black et al., 2011; Culler et al., 2006;
Garg et al., 2005; Reckmann et al., 2009).
Many studies, including meta-analyses, offer strong evidence that com-
puterization of prescribing can dramatically improve patient safety. These
products were consistently correlated with lowering the frequency of medi-
cation errors and may be able to reduce preventable adverse drug events
significantly (Kaushal et al., 2003; Shamliyan et al., 2008; Wolfstadt et al.,
2008). However, the degree to which health IT can lower medication errors
varies widely among the different computerized prescribing systems used
(Nanji et al., 2011).
The evidence of similar impact outside of medication safety is much
weaker (Bates and Gawande, 2003). Indeed, some systematic reviews con-
clude that the current literature is insufficient to establish any beneficial
impact of health IT on patient safety and health outcomes (Black et al.,
2011; Garg et al., 2005; Reckmann et al., 2009). More recently, new data
have emerged, suggesting that health IT can introduce new patient safety
challenges into the health care system (Magrabi et al., 2010, 2011). These
studies are unable to accurately quantify the number of people harmed by
health IT. This inability of the committee to quantify the harm makes it
difficult to understand the tradeoffs between the potential safety benefits
and harms caused by health IT.
The differing results found in the literature may be due to a variety
of reasons. Among those reasons are the heterogeneous nature of health
IT—including the differences in the products themselves, how they are
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implemented, and how they are used across care settings. Most studies
focused on health IT and patient safety examined care at a single medical
center, often with homegrown IT systems. Aggregating many single-center
studies, such as those common throughout the literature, does not neces-
sarily lead to the same outcomes as having a few studies that are conducted
in a broader array of clinical settings. However, systematic reviews have
attempted to aggregate these studies and have done so in inconsistent ways,
often choosing to include low-quality studies while failing to include higher-
quality ones. Therefore, the committee could not point to any systematic
reviews or studies as representing the most definitive evidence of the impact
of health IT on patient safety (see Table B-1).
A major challenge in quantifying the harm that might result from health
IT is the lack of data in this area. However, the absence of quantifiable
evidence of health IT's harm is not evidence that health IT does not create
harm. It is clear that harm exists. The current literature does not sufficiently
produce estimates on the harm that might result from health IT. For exam-
ple, a recent study by Nanji et al. evaluated the frequency, types, and causes
of errors associated with outpatient computer-generated prescriptions. The
study evaluated 3,850 prescriptions and found 466 errors, involving almost
12 percent of the orders. Because the error rates varied widely between
different computerized prescribing systems (from 5.1 to 37.5 percent), the
authors strongly recommended that users evaluate the safety of each system
(Nanji et al., 2011). However, the authors were not allowed to list which
error rates and safety issues were associated with each particular system.
Instead, the article prescribed a "vigorous vendor selection" process, which
each potential user would have to go through in order to identify safety
concerns of that system. Had the authors been allowed to identify specific
systems with higher error rates, users could know which systems to avoid
and could select systems with characteristics that would best fit their work-
flow and safety needs.
Studies with generic descriptions of health IT products and patient
safety issues will be of little utility to users because health IT products—
even those made by the same manufacturers—are heterogeneous, tailored
to individual clinical settings, and have varying impacts on patient safety.
Therefore, to assist users in selecting the safest health IT product for their
unique clinical environment, studies need to be able to name specific health
IT products, describe how those products have been implemented, and
identify their impact on patient safety in different clinical environments.
For example, as mentioned in Box 2-1, a Pittsburgh pediatric intensive
care unit's (ICU's) implementation of a CPOE system resulted in higher
mortality; however, several different hospitals were able to subsequently
identify safety problems associated with Pittsburgh's experience and imple-
mented the same CPOE system with either no change or up to a 20 percent
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decrease in hospital-wide patient mortality (Longhurst et al., 2010). In
order to identify problems associated with the Pittsburgh implementation,
a pediatric ICU in Seattle sent researchers to Pittsburgh's facilities, met
with their administrative and clinical leadership, and spoke with clinical
staff. After months of correspondence, the Seattle pediatric ICU was able
to determine why Pittsburgh's implementation resulted in a higher mortality
rate and was able to avoid such problems (Del Beccaro et al., 2006; Han et
al., 2005). When selecting health IT products, many potential users do not
have the time or the resources to spend months corresponding, visiting, and
observing other hospitals. Users and researchers need to be encouraged to
provide specific descriptions of safety problems associated with particular
health IT products in order to provide potential users with credible data
regarding which IT products are safer than others.
When researchers, consumer groups, and users attempt to identify
and share information on health IT features related to adverse events and
patient safety risks, they can be faced with barriers created by market
inefficiencies within health IT, such as lack of information available to
consumers and the inability of users to freely move between health IT
products. For example, because the impact of health IT in each clini-
cal environment is extremely diverse and highly dependent on the user's
specific clinical environment, it is difficult for clinicians to know how
the myriad of different health IT products will affect patient safety. Ad-
ditionally, because of the substantial costs and effort used in tailoring and
integrating health IT products, users may not be able to readily switch
products after discovering patient safety problems. Many health IT prod-
ucts can only be maintained by the manufacturer of that product, causing
users to maintain service contracts with that manufacturer, regardless of
whether that manufacturer addresses patient safety issues associated with
its product. Even if users are willing to switch health IT products, there is
no guarantee another product will achieve greater levels of patient safety,
once integrated. These inefficiencies result in an inadequate understanding
of how health IT impacts patient safety and leads users to select and make
a long-term commitment to products that may not adequately complement
their clinical environment.
To increase understanding of how health IT affects patient safety and
allows users to make informed decisions, it is important that the health
IT community share details, such as screenshots of risk-enhancing inter-
faces, descriptions of potentially unsafe processes, and other components
of health IT products associated with adverse events. Some vendors allow
users to share information through industry conferences, sponsored user
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group meetings, blogs, and consultants that provide conduits for informa-
tion about vendor experiences. However, the ability of users and researchers
to share such information outside industry-controlled venues can be limited
by nondisclosure clauses.
Nondisclosure clauses—commonly found in many types of commercial
contracts and almost always included in software license agreements—are
intended to protect licensors' intellectual property interests, competitive
edge, and liability from consumer misuse of their products1 (Koppel and
Kreda, 2009). The fear of violating nondisclosure clauses and intellec-
tual property interests may discourage users from sharing health IT–
related patient safety risks. Additionally, if users believe that hold-harmless
clauses, which are placed in many vendor contracts, can shift the liability
of unsafe health IT features solely to the user, they may fear that disclosing
unsafe features may unfairly increase their risk of liability.
To adequately understand how health IT impacts patient safety, users
and researchers need to be able to share information that may normally
be protected by intellectual property rights or may expose users to un-
fair liability. Some vendors have expended considerable effort to ensure
patient safety, but allowing the disclosure of patient safety issues may
cause vendors to lose their competitive advantage. Thus, some vendors
may impose or enforce such restrictions in ways that may conceal patient
safety issues2 (Koppel and Kreda, 2009). As long as vendors may restrict
the release of information about safety issues through confidentiality
clauses, intellectual property protections, and hold-harmless clauses, the
health care community will be limited in its understanding of how health
IT affects patient safety.
Because the nature of these legal issues limits publicly available infor-
mation, very little evidence establishes their frequency of use or impact
on users (Koppel and Kreda, 2009). However, the committee believes that
these types of contractual restrictions limit transparency, which significantly
contributes to the gaps in knowledge of health IT–related patient safety
risks. Regardless of whether these barriers have actually been used to
prevent reporting, the fear of legal action itself may prevent health profes-
sionals from sharing crucial health IT–related information with researchers,
consumer groups, other users, and the government. As stated by the Ameri-
can Medical Informatics Association, such clauses should be considered
unethical (Goodman et al., 2011).
1 Personal communication, B. Leshine, LeClairRyan, April 20, 2011; personal communica-
tion, H. Levine, Blaszak, Block & Boothby, LLP, June 10, 2011.
2 Personal communication, B. Leshine, LeClairRyan, April 20, 2011; personal communica-
tion, H. Levine, Blaszak, Block & Boothby, LLP, June 10, 2011.
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The following sections examine how individual components of health
IT affect patient safety. However, most health IT products are not a single
component, but a complex system of health IT components, sometimes
collectively referred to as electronic health records (EHRs). Although the
definition of EHRs can vary substantially, there are generally four core
components of an EHR: electronic clinical documentation (usually physi-
cian, nurse, and other clinician documentation), electronic prescribing (e.g.,
computerized provider order entry), results reporting and management
(e.g., clinical data repository), and clinical decision support (DesRoches et
al., 2008; Jha et al., 2006, 2009a, 2009b). Many EHRs also include bar-
coding systems and patient engagement tools. The Office of the National
Coordinator for Health Information Technology (ONC) defines an EHR as
"a real-time patient health record with access to evidence-based decision
support tools that can be used to aid clinicians in decision-making. The
EHR can automate and streamline a clinician's workflow, ensuring that all
clinical information is communicated. It can also prevent delays in response
that result in gaps in care. The EHR can also support the collection of
data for uses other than clinical care, such as billing, quality management,
outcome reporting, and public health disease surveillance and reporting"
Although EHR and health IT are terms that are still evolving and are
often interpreted differently, much of the evidence regarding the impact of
EHRs on patient safety has focused on individual components of EHRs.
The following sections explore the evidence for individual components and
then discuss the evidence from studies that use the "EHR" as a general
term.3 Because almost every component uses documentation and results
review and management throughout their tasks (bar-coding, CPOE, and
CDS systems all use documentation and results reporting and management
in prescribing and delivering medication), this chapter will not address
documentation results reporting and management individually. The section
then looks at how current EHR systems can be leveraged to further improve
patient safety. Table 2-1 summarizes the benefits and safety concerns com-
monly found in the literature.
3 Although there are many other components of health IT, the bulk of the literature has
focused on the following components: EHR, CPOE systems, CDS systems, patient engage-
ment tools, and bar-coding systems. Some other components not listed in this chapter include
medication reconciliation systems and smartpumps; see Appendix B.
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Potential Benefits and Safety Concerns of Health IT Components
Computerized Provider Order Entry (CPOE)
An electronic system that allows providers to record, store, retrieve, and modify
orders (e.g., prescriptions, diagnostic testing, treatment, and/or radiology/imaging
Potential Benefits Safety Concerns
– Large increases in legible orders – Increases relative risk of medication
– Shorter order turnaround times
– Increased ordering time
– Lower relative risk of medication errors
– New opportunities for errors, such as:
– Higher percentage of patients who at-
• fragmented displays preventing
tain their treatment goals
a coherent view of patients'
• inflexible ordering formats
generating wrong orders
• separations in functions that
facilitate double dosing
• incompatible orders
– Disruptions in workflow
Clinical Decision Support (CDS)
Monitors and alerts clinicians of patient conditions, prescriptions, and treatment to
provide evidence-based clinical suggestions to health professionals at the point of
Potential Benefits Safety Concerns
– Reductions in: – Rate of detecting drug–drug
• relative risk of medication errors interactions varies widely among
• risk of toxic drug levels different vendors
• time to therapeutic stabilization – Increases in mortality rate
• management errors of resuscitating
– High override rate of computer
patients in adult trauma centers
generated alerts (alert fatigue)
• prescriptions of nonpreferred
– Can effectively monitor and alert
clinicians of adverse conditions
– Improve long-term treatment and
increase the likelihood of achieving
treatment goals
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TABLE 2-1 Continued
Bar-coding can be used to track medications, orders, and other health care products.
It can also be used to verify patient identification and dosage.
Potential Benefits Safety Concerns
– Significant reductions in relative risk – Introduction of workarounds; for
of medication errors associated with: example, clinicians can:
• transcription • scan medications and patient
• dispensing identification without visually
• administration errors checking to see if the medication,
dosing, and patient identification
are correct
• attach patient identification
bar-codes to another object instead
of the patient
• scan orders and medications of
multiple patients at once instead
of doing it each time the medica-
tion is dispensed
Patient Engagement Tools
Tools such as patient portals, smartphone applications, email, and interactive kiosks,
which enable patients to participate in their health care treatment.
Potential Benefits Safety Concerns
– Reduction in hospitalization rates – Reliability of data entered by:
in children • patients,
• families,
– Increases in patients' knowledge
• friends, or
of treatment and illnesses
• unauthorized users
NOTE: Table 2-1 is not intended to be an exhaustive list of all potential benefits and safety concerns associated
with health IT. It represents the most common potential benefits and safety concerns.
Computerized Provider Order Entry
CPOE is an electronic system that allows providers to record, store, re-
trieve, and modify orders (e.g., prescriptions, diagnostic testing, treatment,
and radiology/imaging orders). The use of CPOE has varying degrees of
impact on patient safety, depending on how well the CPOE system comple-
ments or improves provider workflow. The successful impact of a CPOE
system on patient safety may also depend heavily on the change manage-
ment approach employed by organizational leadership to prepare clinicians
and recipients of the new workflow, as well as the decision support tools
associated with it. Short-term benefits of CPOE systems commonly found
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in studies include large increases in legible orders, shorter order turnaround
times, lower relative risk of medication errors, and a higher percentage of
patients who attain their treatment goals (Devine et al., 2010; Nam et al.,
2007; Niazkhani et al., 2009). In the inpatient setting, a series of literature
reviews and meta-analyses found that medication error rates fell (Kaushal
et al., 2003; Shamliyan et al., 2008; Wolfstadt et al., 2008) due to the intro-
duction of a CPOE system and most, though not all, studies suggest that
the preventable adverse drug events (ADEs) rate decreases as well. Studies
suggest that CPOE systems have a greater impact when designed for the
specific needs of the hospital environment, workflow, and providers (Callen
et al., 2010). For example, CPOE systems with order sets specifically de-
signed for ICUs can increase efficiency and workflow (Ali et al., 2005).
Although the potential benefits of CPOE systems are well established,
the harms that have been well articulated on a case-by-case basis have rela-
tively little empirical basis behind them (Aleccia, 2011; Associated Press,
2009; Graham and Dizikes, 2011; Schulte and Schwartz, 2010; Silver and
Hamill, 2011; U.S. News, 2011). The lack of data on harm is driven in
large part, as described earlier, by practices that limit disclosure of health
IT–related adverse drug events. Based on the existing information, it seems
likely that, if these systems are either designed poorly or interface with cli-
nicians in an ineffective manner, they can cause harm. Several experts have
suggested that CPOE systems can have a number of potential adverse con-
sequences, including increased ordering time, disruptions in workflow, new
opportunities for errors (e.g., fragmented displays preventing a coherent
view of patients' medications, inflexible ordering formats generating wrong
orders, separations of functions that facilitate double dosing, and incompat-
ible orders), and increased relative risk of medication errors (Koppel et al.,
2005; Niazkhani et al., 2009; Santell et al., 2009; Singh et al., 2009; Walsh
et al., 2006; Weant et al., 2007).
Some of the variability in the impact of CPOE systems is likely due to
differences in decision support systems that can detect potential errors and/
or generate care suggestions. For example, a CPOE system was introduced
to a pediatric ICU without a CDS and resulted in no significant change in
the rate of potential adverse drug events. However, a significant reduction
in potential adverse drug events was found after a CDS system was imple-
mented (Kadmon et al., 2009). Further discussion regarding the impact of
CDS on patient safety is examined in the next section.
Clinical Decision Support
CDS systems are also an important component of an EHR. They
can monitor patient conditions, prescriptions, and treatment to provide
evidence-based clinical suggestions to health professionals at the point of
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which health IT has played a key role. For example, the World Health
Organization's (WHO's) patient safety program has 13 specific patient
safety action areas that focus on patient safety as a global health care issue.
These action areas are aimed to "coordinate, disseminate, and accelerate
improvements in patient safety worldwide" (WHO, 2011a). Although it
focuses on a broad range of safety issues, "Action Area 8: Technology and
Patient Safety," most specifically, targets systemic and technical aspects to
improve patient safety around the world by promoting personal health
records (PHRs), automated prescribing systems, simulation training, and
failsafe mechanisms in diagnostic tools, such as computerized radiographs
(WHO, 2008, 2011a, 2011b).
On a similarly large scale, the European Union (EU) has funded specific
eHealth initiatives (EU, 2010a) and the use of technology to improve the
quality and safety of care delivered during disaster response efforts (EU,
2007). These programs focus on PHRs, patient guidance services, virtual
physiological humans, and computer simulations. The EU is supporting sev-
eral efforts using information and communication technologies to improve
patient safety, focusing on the "development of advanced applications to
improve risk assessment and patient safety" (EU, 2010b). In 2009 alone,
the EU invested €28 million (EU, 2010b), including programs such as
Patient Safety through Intelligent Procedures in Medication (PSIP), whose
main aim is to develop computer applications and to educate providers and
patients on how to prevent medication errors (PSIP, 2011). Additionally, the
Safety for Robotic Surgery (SAFROS) project seeks to develop technologies
for patient safety in robotic surgery (SAFROS, 2009).
Broad country comparison studies have been conducted on the use
of health IT and its potential to improve patient safety. For example, an
international cross-sectional study examined health IT's functional capacity
and quality of care delivered in Australia, Canada, Denmark, Germany, the
Netherlands, New Zealand, the United Kingdom, and the United States.
The study found that, when controlling for within country differences of
specific health IT methods adopted and primary care physician (PCP) prac-
tice sizes, significant disparities exist in the quality of care delivered among
practices with low IT capacity compared to those with high IT capacity.
IT functional capacity was measured through a count of 14 different items
(such as whether the clinician used an EHR, prescribed medicine elec-
tronically, and had a computerized system for patient reminders, prompts
for potential drug interaction, and test results). Practices were deemed
"low" if they had 2 or fewer of the 14 items and "high" if they had between
7 and 14 items (Davis et al., 2009).
Although the study focused on several outcomes, the specific safety
outcome measured was whether a physician practice had a specific, docu-
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mented process for patient follow-up and analysis of adverse events. Thirty-
eight percent of physicians had a documented process for all adverse events
(ranging from 27 percent of physicians in low-capacity countries to 43
percent in high-capacity countries), while 17 percent of physicians had a
process for adverse drug reactions online (ranging from 22 percent in low-
capacity countries to 15 percent in high-capacity countries) (Davis et al.,
2009). Approximately 50 percent of practices with low IT capacity reported
no processes for following up on adverse events compared to 41 percent of
practices with higher IT functionality. Researchers suggested that countries
that support a stronger IT infrastructure are better suited to address coor-
dination of care and safety issues, as well as to maintain satisfaction among
the PCP community (Davis et al., 2009).
Other country-specific studies have been conducted, including a series
of papers comparing the adoption of health IT among PCP offices in New
Zealand and Denmark, two countries leading the way in the adoption of
health IT over the past two decades (Protti et al., 2008a, 2008b, 2008c,
2008d, 2009). These studies suggest that it has been possible for many
nations to adopt and use health IT in PCP practices without measurable,
deleterious consequences on patient safety.
Although the United States has made significant strides in health IT
over the past 20 years, it is clear that many other high-income nations are
much further ahead in IT adoption, at least in the ambulatory setting. De-
spite the fact that these other nations have had a much greater experience
with health IT, there is very little direct information on the impact of their
investments on patient safety. The primary lesson for the United States is
that it is possible to have widespread adoption of health IT without harm-
ing safety. What the optimal strategies are for doing so cannot be so easily
gleaned by looking at these other nations.
Health IT has already been shown to improve medication safety. Al-
though the evidence is mixed for areas outside of medication safety, both
within the United States and abroad, the fact that several studies have im-
proved patient safety with implementation of health IT leads the committee
to believe that health IT has at least the potential to drastically improve
patient safety in other areas of care. As with any new technology, health IT
carries benefits and risks of new and greater harms. To fully capitalize on
the potential that health IT may have on patient safety, a more comprehen-
sive understanding of how health IT impacts potential harms, workflow,
and safety is needed.
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Abarca, J., L. R. Colon, V. S. Wang, D. C. Malone, J. E. Murphy, and E. P. Armstrong. 2006.
Evaluation of the performance of drug-drug interaction screening software in community
and hospital pharmacies. Journal of Managed Care Pharmacy 12(5):383-389.
Agostini, J. V., Y. Zhang, and S. K. Inouye. 2007. Use of a computer-based reminder to im-
prove sedative-hypnotic prescribing in older hospitalized patients. Journal of the Ameri-
can Geriatrics Society 55(1):43-48.
Aleccia, J. 2011. Nurse's suicide highlights twin tragedies of medical errors. MSNBC.com. http://
tragedies-medical-errors/#.Tph_EHI2Y9Y (accessed October 14, 2011).
Ali, N. A., H. S. Mekhjian, P. L. Kuehn, T. D. Bentley, R. Kumar, A. K. Ferketich, and S. P.
Hoffmann. 2005. Specificity of computerized physician order entry has a significant
effect on the efficiency of workflow for critically ill patients. Critical Care Medicine
Ammenwerth, E., P. Schnell-Inderst, C. Machan, and U. Siebert. 2008. The effect of electronic
prescribing on medication errors and adverse drug events: A systematic review. Journal
of the American Medical Informatics Association 15(5):585-600.
Ash, J. S., D. F. Sittig, R. Dykstra, E. Campbell, and K. Guappone. 2009. The unintended
consequences of computerized provider order entry: Findings from a mixed methods
exploration. International Journal of Medical Informatics 78(Suppl 1):S69-S76.
Associated Press. 2009. Veterans given wrong drug doses due to glitch. MSNBC.com. http://
www.msnbc.msn.com/id/28655104/#.Tph-b3I2Y9Z (accessed October 14, 2011).
Bates, D. W., and A. A. Gawande. 2003. Improving safety with information technology. New
England Journal of Medicine 348(25):2526-2534.
Bates, D. W., G. J. Kuperman, S. Wang, T. Gandhi, A. Kittler, L. Volk, C. Spurr, R. Khorasani,
M. Tanasijevic, and B. Middleton. 2003. Ten commandments for effective clinical deci-
sion support: Making the practice of evidence-based medicine a reality. Journal of the
American Medical Informatics Association 10(6):523-530.
Begley, S. 2011. The best medicine: Cutting health costs with comparative effectiveness re-
search. Scientific American. http://www.scientificamerican.com/article.cfm?id=the-best-
medicine-july-11 (accessed August 5, 2011).
Benham-Hutchins, M. M., and J. A. Effken. 2010. Multi-professional patterns and methods
of communication during patient handoffs. International Journal of Medical Informatics
Black, A. D., J. Car, C. Pagliari, C. Anandan, K. Cresswell, T. Bokun, B. McKinstry, R. Procter,
A. Majeed, and A. Sheikh. 2011. The impact of eHealth on the quality and safety of
health care: A systematic overview. Public Library of Science Medicine 8(1).
Callen, J., R. Paoloni, A. Georgiou, M. Prgomet, and J. Westbrook. 2010. The rate of missed
test results in an emergency department an evaluation using an electronic test order and
results viewing system. Methods of Information in Medicine 49(1):37-43.
Claridge, J. A., J. F. Golob, A. M. A. Fadlalla, B. M. D'Amico, J. R. Peerless, C. J. Yowler, and
M. A. Malangoni. 2009. Who is monitoring your infections: Shouldn't you be? Surgical
Infections 10(1):59-64.
Classen, D. C., S. L. Pestotnik, R. S. Evans, and J. P. Burke. 1991. Computerized surveillance
of adverse drug events in hospital patients. Journal of the American Medical Association
Classen, D. C., R. Resar, F. Griffin, F. Federico, T. Frankel, N. Kimmel, J. C. Whittington,
A. Frankel, A. Seger, and B. C. James. 2011. "Global trigger tool" shows that adverse
events in hospitals may be ten times greater than previously measured. Health Affairs
OCR for page 31
Conroy, S., D. Sweis, C. Planner, V. Yeung, J. Collier, L. Haines, and I. C. K. Wong. 2007.
Interventions to reduce dosing errors in children—a systematic review of the literature.
Drug Safety 30(12):1111-1125.
Culler, S. D., A. Atherly, S. Walczak, A. Davis, J. N. Hawley, K. J. Rask, V. Naylor, and K. E.
Thorpe. 2006. Urban-rural differences in the availability of hospital information technol-
ogy applications: A survey of Georgia hospitals. Journal of Rural Health 22(3):242-247.
Davis, K., M. M. Doty, K. Shea, and K. Stremikis. 2009. Health information technology and
physician perceptions of quality of care and satisfaction. Health Policy 90(2-3):239-246.
Del Beccaro, M. A., H. E. Jeffries, M. A. Eisenberg, and E. D. Harry. 2006. Computerized
provider order entry implementation: No association with increased mortality rates in
an intensive care unit. Pediatrics 118(1):290-295.
DesRoches, C. M., E. G. Campbell, S. R. Rao, K. Donelan, T. G. Ferris, A. Jha, R. Kaushal,
D. E. Levy, S. Rosenbaum, A. E. Shields, and D. Blumenthal. 2008. Electronic health
records in ambulatory care—a national survey of physicians. New England Journal of
Medicine 359(1):50-60.
DesRoches, C. M., E. G. Campbell, C. Vogeli, J. Zheng, S. R. Rao, A. E. Shields, K. Donelan,
S. Rosenbaum, S. J. Bristol, and A. K. Jha. 2010. Electronic health records' limited suc-
cesses suggest more targeted uses. Health Affairs 29(4):639-646.
Devine, E. B., R. N. Hansen, J. L. Wilson-Norton, N. M. Lawless, A. W. Fisk, D. K. Blough,
D. P. Martin, and S. D. Sullivan. 2010. The impact of computerized provider order entry
on medication errors in a multispecialty group practice. Journal of the American Medical
Informatics Association 17(1):78-84.
Dorr, D., L. M. Bonner, A. N. Cohen, R. S. Shoai, R. Perrin, E. Chaney, and A. S. Young. 2007.
Informatics systems to promote improved care for chronic illness: A literature review.
Journal of the American Medical Informatics Association 14(2):156-163.
Durieux, P., L. Trinquart, I. Colombet, J. Niès, R. Walton, A. Rajeswaran, M. Rège-Walther,
E. Harvey, and B. Burnand. 2008. Computerized advice on drug dosage to improve pre-
scribing practice. Cochrane Database of Systematic Reviews (3):CD002894.
Einbinder, J. S., and D. W. Bates. 2007. Leveraging information technology to improve quality
and safety. Yearbook of Medical Informatics 2007:22-29.
EU (European Union). 2007. Managing disasters and emergencies. http://ec.europa.eu/
information_society/tl/qualif/safety/index_en.htm (accessed June 20, 2011).
EU. 2010a. Research in eHealth. http://ec.europa.eu/information_society/activities/health/
research/index_en.htm (accessed June 20, 2011).
EU. 2010b. Risk assessment and patient safety. http://ec.europa.eu/information_society/
activities/health/research/fp7ps/index_en.htm (accessed June 20, 2011).
Evans, R. S., S. L. Pestotnik, D. C. Classen, T. P. Clemmer, L. K. Weaver, J. F. Orme, J. F.
Lloyd, and J. P. Burke. 1998. A computer-assisted management program for antibiotics
and other antiinfective agents. New England Journal of Medicine 338(4):232-238.
Feldstein, A. C., W. M. Vollmer, D. H. Smith, A. Petrik, J. Schneider, H. Glauber, and M.
Herson. 2007. An outreach program improved osteoporosis management after a fracture.
Journal of the American Geriatrics Society 55(9):1464-1469.
Ferris, T. G., S. A. Johnson, J. P. T. Co, M. Backus, J. Perrin, D. W. Bates, and E. G. Poon.
2009. Electronic results management in pediatric ambulatory care: Qualitative assess-
ment. Pediatrics 123(Suppl 2):S85-S91.
Fitzgerald, M., P. Cameron, C. Mackenzie, N. Farrow, P. Scicluna, R. Gocentas, A. Bystrzycki,
G. Lee, G. O'Reilly, N. Andrianopoulos, L. Dziukas, D. J. Cooper, A. Silvers, A. Mori,
A. Murray, S. Smith, Y. Xiao, D. Stub, F. T. McDermott, and J. V. Rosenfeld. 2011.
Trauma resuscitation errors and computer-assisted decision support. Archives of Surgery
OCR for page 31
Franklin, B. D., K. O'Grady, P. Donyai, A. Jacklin, and N. Barber. 2007. The impact of a
closed-loop electronic prescribing and administration system on prescribing errors, ad-
ministration errors and staff time: A before-and-after study. Quality & Safety in Health
Care 16(4):279-284.
Gandhi, T. K., S. B. Bartel, L. N. Shulman, D. Verrier, E. Burdick, A. Cleary, J. M. Rothschild,
L. L. Leape, and D. W. Bates. 2005. Medication safety in the ambulatory chemotherapy
setting. Cancer 104(11):2477-2483.
Gandhi, T. K., A. Kachalia, E. J. Thomas, A. L. Puopolo, C. Yoon, T. A. Brennan, and D.
M. Studdert. 2006. Missed and delayed diagnoses in the ambulatory setting: A study of
closed malpractice claims. Annals of Internal Medicine 145(7):488-496.
Garg, A., N. Adhikari, H. McDonald, M. Rosas-Arellano, P. Devereaux, J. Beyene, J. Sam,
and R. Haynes. 2005. Effects of computerized clinical decision support systems on prac-
titioner performance and patient outcomes: A systematic review. Journal of the American
Medical Association 293(10):1223-1238.
Gearing, P., C. M. Olney, K. Davis, D. Lozano, L. B. Smith, and B. Friedman. 2006. Enhancing
patient safety through electronic medical record documentation of vital signs. Journal of
Healthcare Information Management 20(4):40-45.
Georgiou, A., M. Williamson, J. I. Westbrook, and S. Ray. 2007. The impact of computerised
physician order entry systems on pathology services: A systematic review. International
Journal of Medical Informatics 76(7):514-529.
Glassman, P. A., P. Belperio, A. Lanto, B. Simon, R. Valuck, J. Sayers, and M. Lee. 2007.
The utility of adding retrospective medication profiling to computerized provider order
entry in an ambulatory care population. Journal of the American Medical Informatics
Association 14(4):424-431.
Gohil, B., H. Gholamhosseini, M. J. Harrison, A. Lowe, and A. Al-Jumaily. 2007. Intelligent
monitoring of critical pathological events during anesthesia. Paper presented at Annual
International Conference of the IEEE Engineering in Medicine & Biology Society, Lyon,
Goodman, K. W., E. S. Berner, M. A. Dente, B. Kaplan, R. Koppel, D. Rucker, D. Z. Sands, P.
Winkelstein, and the AMIA Board of Directors. 2011. Challenges in ethics, safety, best
practices, and oversight regarding HIT vendors, their customers, and patients: A report
of an AMIA special task force. Journal of the American Medical Informatics Association
Gordon, J. R. S., T. Wahls, R. C. Carlos, I. I. Pipinos, G. E. Rosenthal, and P. Cram. 2009.
Failure to recognize newly identified aortic dilations in a health care system with an ad-
vanced electronic medical record. Annals of Internal Medicine 151(1):21-27.
Graham, D. J., D. Campen, R. Hui, M. Spence, C. Cheetham, G. Levy, S. Shoor, and W. A. Ray.
2005. Risk of acute myocardial infarction and sudden cardiac death in patients treated
with cyclo-oxygenase 2 selective and non-selective non-steroidal anti-inflammatory drugs:
Nested case-control study. The Lancet 365(9458):475-481.
Graham, J., and C. Dizikes. 2011. Baby's death spotlights safety risks linked to comput-
erized systems. Los Angeles Times. http://www.latimes.com/health/ct-met-technology-
errors-20110627,0,2158183.story (accessed June 29, 2011).
Greenhalgh, T., K. Stramer, T. Bratan, E. Byrne, Y. Mohammad, and J. Russell. 2008. Intro-
duction of shared electronic records: Multi-site case study using diffusion of innovation
theory. British Medical Journal 337:a1786.
Gurwitz, J. H., T. S. Field, J. Judge, P. Rochon, L. R. Harrold, C. Cadoret, M. Lee, K. White,
J. LaPrino, J. Erramuspe-Mainard, M. DeFlorio, L. Gavendo, J. Auger, and D. W. Bates.
2005. The incidence of adverse drug events in two large academic long-term care facili-
ties. American Journal of Medicine 118(3):251-258.
OCR for page 31
Han, Y. Y., J. A. Carcillo, S. T. Venkataraman, R. S. B. Clark, R. S. Watson, T. C. Nguyen, H.
Bayir, and R. A. Orr. 2005. Unexpected increased mortality after implementation of a com-
mercially sold computerized physician order entry system. Pediatrics 116(6):1506-1512.
Hayrinen, K., K. Saranto, and P. Nykanen. 2008. Definition, structure, content, use and
impacts of electronic health records: A review of the research literature. International
Journal of Medical Informatics 77(5):291-304.
Herasevich, V., M. Yilmaz, H. Khan, R. D. Hubmayr, and O. Gajic. 2009. Validation
of an electronic surveillance system for acute lung injury. Intensive Care Medicine
HHS (U.S. Department of Health and Human Services). 2004. Health IT strategic framework:
Glossary of selected terms (accessed May 9, 2011).
IOM (Institute of Medicine). 2004. Patient safety: Achieving a new standard for care. Wash-
ington, DC: The National Academies Press.
Isaac, T., J. S. Weissman, R. B. Davis, M. Massagli, A. Cyrulik, D. Z. Sands, and S. N.
Weingart. 2009. Overrides of medication alerts in ambulatory care. Archives of Internal
Medicine 169(3):305-311.
Jha, A. K., G. J. Kuperman, J. M. Teich, L. Leape, B. Shea, E. Rittenberg, E. Burdick, D. L.
Seger, M. V. Vliet, and D. W. Bates. 1998. Identifying adverse drug events. Journal of the
American Medical Informatics Association 5(3):305-314.
Jha, A. K., T. G. Ferris, K. Donelan, C. DesRoches, A. Shields, S. Rosenbaum, and D.
Blumenthal. 2006. How common are electronic health records in the United States? A
summary of the evidence. Health Affairs 25(6):w496-w507.
Jha, A. K., J. Laguette, A. Seger, and D. W. Bates. 2008. Can surveillance system identify and
avert adverse drug events? A prospective evaluation of a commercial application. Journal
of the American Medical Informatics Association 15(5):647-653.
Jha, A. K., C. M. DesRoches, E. G. Campbell, K. Donelan, S. R. Rao, T. G. Ferris, A. Shields,
S. Rosenbaum, and D. Blumenthal. 2009a. Use of electronic health records in U.S.
hospitals. New England Journal of Medicine 360(16):1628-1638.
Jha, A. K., E. J. Orav, and A. M. Epstein. 2009b. Preventing readmissions with improved
hospital discharge planning. New England Journal of Medicine 361(27):2637-2645.
Kadmon, G., E. Bron-Harlev, E. Nahum, O. Schiller, G. Haski, and T. Shonfeld. 2009. Com-
puterized order entry with limited decision support to prevent prescription errors in a
PICU. Pediatrics 124(3):935-940.
Kaushal, R., K. G. Shojania, and D. W. Bates. 2003. Effects of computerized physician order
entry and clinical decision support systems on medication safety: A systematic review.
Archives of Internal Medicine 163(12):1409-1416.
Koppel, R., and D. Kreda. 2009. Health care information technology vendors' "hold harm-
less" clause. Journal of the American Medical Association 301(12):1276-1278.
Koppel, R., J. P. Metlay, A. Cohen, B. Abaluck, A. R. Localio, S. E. Kimmel, and B. L. Strom.
2005. Role of computerized physician order entry systems in facilitating medication
errors. Journal of the American Medical Association 293(10):1197-1203.
Koppel, R., T. Wetterneck, J. L. Telles, and B. T. Karsh. 2008. Workarounds to barcode medi-
cation administration systems: Their occurrences, causes, and threats to patient safety.
Journal of the American Medical Informatics Association 15(4):408-423.
Kravitz, R. L., J. E. Rolph, and L. Petersen. 1997. Omission-related malpractice claims and
the limits of defensive medicine. Medical Care Research and Review 54(4):456-471.
Lin, C. P., T. H. Payne, W. P. Nichol, P. J. Hoey, C. L. Andreson, and J. H. Gennari. 2008.
Evaluating clinical decision support systems: Monitoring CPOE order check override
rates in the Department of Veterans Affairs' computerized patient record system. Journal
of the American Medical Informatics Association 15(5):620-626.
OCR for page 31
Litaker, D., C. Ritter, S. Ober, and D. Aron. 2005. Continuity of care and cardiovascular risk
factor management: Does care by a single clinician add to informational continuity pro-
vided by electronic medical records? American Journal of Managed Care 11(11):689-696.
Longhurst, C. A., L. Parast, C. I. Sandborg, E. Widen, J. Sullivan, J. S. Hahn, C. G. Dawes,
and P. J. Sharek. 2010. Decrease in hospital-wide mortality rate after implementation of
a commercially sold computerized physician order entry system. Pediatrics 126(1):14-21.
Magid, D. J., S. M. Shetterly, K. L. Margolis, H. M. Tavel, P. J. O'Connor, J. V. Selby, and
P. M. Ho. 2010. Comparative effectiveness of angiotensin-converting enzyme inhibitors
versus β-blockers as second-line therapy for hypertension. Circulation: Cardiovascular
Quality and Outcomes 3(5):453-458.
Magrabi, F., S. Y. W. Li, R. O. Day, and E. Coiera. 2010. Errors and electronic prescribing: A
controlled laboratory study to examine task complexity and interruption effects. Journal
of the American Medical Informatics Association 17(5):575-583.
Magrabi, F., M.-S. Ong, W. Runciman, and E. Coiera. 2011. Using FDA reports to inform a
classification for health information technology safety problems. Journal of the American
Medical Informatics Association 19(1):45-53.
Matheny, M. E., T. K. Gandhi, E. J. Orav, Z. Ladak-Merchant, D. W. Bates, G. J. Kuperman,
and E. G. Poon. 2007. Impact of an automated test results management system on
patients' satisfaction about test result communication. Archives of Internal Medicine
Metzger, J., E. Welebob, D. W. Bates, S. Lipsitz, and D. C. Classen. 2010. Mixed results in the
safety performance of computerized physician order entry. Health Affairs 29(4):655-663.
Murray, E., J. Burns, T. S. See, R. Lai, and I. Nazareth. 2009. Interactive health communi-
cation applications for people with chronic disease. Cochrane Database of Systematic
Reviews (1):CD004274.
Nam, H. S., S. W. Han, S. H. Ahn, J. Y. Lee, H. Y. Choi, I. C. Park, and J. H. Heo. 2007.
Improved time intervals by implementation of computerized physician order entry-based
stroke team approach. Cerebrovascular Diseases 23(4):289-293.
Nanji, K. C., J. M. Rothschild, C. Salzberg, C. A. Keohane, K. Zigmont, J. Devita, T. K.
Gandhi, A. K. Dalal, D. W. Bates, and E. G. Poon. 2011. Errors associated with out-
patient computerized prescribing systems. Journal of the American Medical Informatics
Association 18(6):767-773.
Ngo-Metzger, Q., G. R. Hayes, Y. N. Chen, R. Cygan, and C. F. Garfield. 2010. Improving
communication between patients and providers using health information technology
and other quality improvement strategies: Focus on low-income children. Medical Care
Research and Review 67(5):246S-267S.
Niazkhani, Z., H. Pirnejad, M. Berg, and J. Aarts. 2009. The impact of computerized provider
order entry systems on inpatient clinical workflow: A literature review. Journal of the
American Medical Informatics Association 16(4):539-549.
Nies, J., I. Colombet, E. Zapletal, F. Gillaizeau, P. Chevalier, and P. Durieux. 2010. Effects
of automated alerts on unnecessarily repeated serology tests in a cardiovascular surgery
department: A time series analysis. Health Services Research 10(1):70.
ONC (Office of the National Coordinator for Health Information Technology). 2009. Health
IT terms: Glossary of selected terms related to Health IT. http://healthit.hhs.gov/portal/
server.pt?open=512&mode=2&cached=true&objID=1256&PageID=15726 (accessed
March 20, 2011).
Parente, S. T., and J. S. McCullough. 2009. Health information technology and patient safety:
Evidence from panel data. Health Affairs 28(2):357-360.
OCR for page 31
Phansalkar, S., J. Edworthy, E. Hellier, D. L. Seger, A. Schedlbauer, A. J. Avery, and D. W.
Bates. 2010. A review of human factors principles for the design and implementation of
medication safety alerts in clinical information systems. Journal of the American Medical
Informatics Association 17(5):493-501.
Poon, E. G., T. K. Gandhi, T. D. Sequist, H. J. Murff, A. S. Karson, and D. W. Bates. 2004.
"I wish I had seen this test result earlier!": Dissatisfaction with test result management
systems in primary care. Archives of Internal Medicine 164(20):2223-2228.
Poon, E. G., J. L. Cina, W. Churchill, N. Patel, E. Featherstone, J. M. Rothschild, C. A.
Keohane, A. D. Whittemore, D. W. Bates, and T. K. Gandhi. 2006. Medication dispensing
errors and potential adverse drug events before and after implementing bar code technol-
ogy in the pharmacy. Annals of Internal Medicine 145(6):426-434.
Poon, E. G., C. A. Keohane, C. S. Yoon, M. Ditmore, A. Bane, O. Levtzion-Korach, T. Moniz,
J. M. Rothschild, A. B. Kachalia, J. Hayes, W. W. Churchill, S. Lipsitz, A. D. Whittemore,
D. W. Bates, and T. K. Gandhi. 2010. Effect of bar-code technology on the safety of
medication administration. New England Journal of Medicine 362(18):1698-1707.
Protti, D., T. Bowden, and I. Johansen. 2008a. Adoption of information technology in primary
care physician offices in New Zealand and Denmark, part 1: Healthcare system compari-
sons. Informatics in Primary Care 16:183-187.
Protti, D., T. Bowden, and I. Johansen. 2008b. Adoption of information technology in primary
care physician offices in New Zealand and Denmark, part 2: Historical comparisons.
Informatics in Primary Care 16:189-193.
Protti, D., T. Bowden, and I. Johansen. 2008c. Adoption of information technology in primary
care physician offices in New Zealand and Denmark, part 3: Medical record environment
comparisons. Informatics in Primary Care 16:285-290.
Protti, D., T. Bowden, and I. Johansen. 2008d. Adoption of information technology in pri-
mary care physician offices in New Zealand and Denmark, part 4: Benefits comparisons.
Informatics in Primary Care 16:291-296.
Protti, D., T. Bowden, and I. Johansen. 2009. Adoption of information technology in primary
care physician offices in New Zealand and Denmark, part 5: Final comparisons. Infor-
matics in Primary Care 17:17-22.
PSIP (Patient Safety through Intelligent Procedures in Medication). 2011. PSIP: Patient safety
through intelligent procedures in medication. http://ec.europa.eu/information_society/
activities/health/docs/projects/fp7/psip-factsheet.pdf (accessed June 25, 2011).
Raebel, M. A., J. Charles, J. Dugan, N. M. Carroll, E. J. Korner, D. W. Brand, and D. J. Magid.
2007. Randomized trial to improve prescribing safety in ambulatory elderly patients.
Journal of the American Geriatrics Society 55(7):977-985.
Reckmann, M. H., J. I. Westbrook, Y. Koh, C. Lo, and R. O. Day. 2009. Does computer-
ized provider order entry reduce prescribing errors for hospital inpatients? A systematic
review. Journal of the American Medical Informatics Association 16(5):613-623.
SAFROS (Safety for Robotic Surgery). 2009. The SAFROS project. http://www.safros.eu/
(accessed June 27, 2011).
Santell, J. P., J. G. Kowiatek, R. J. Weber, R. W. Hicks, and C. A. Sirio. 2009. Medication
errors resulting from computer entry by nonprescribers. American Journal of Health-
System Pharmacy 66(9):843-853.
Schulte, F., and E. Schwartz. 2010. As doctors shift to electronic health systems, signs of harm
emerge. Huffington Post Investigative Fund. http://huffpostfund.org/stories/2010/04/
doctors-shift-electronic-health-systems-signs-harm-emerge (accessed October 13, 2010).
Sellier, E., I. Colombet, B. Sabatier, G. Breton, J. Nies, E. Zapletal, J. B. Arlet, D. Somme, and
P. Durieux. 2009. Effect of alerts for drug dosage adjustment in inpatients with renal
insufficiency. Journal of the American Medical Informatics Association 16(2):203-210.
OCR for page 31
Shah, N. R., A. C. Seger, D. L. Seger, J. M. Fiskio, G. J. Kuperman, B. Blumenfeld, E. G.
Recklet, D. W. Bates, and T. K. Gandhi. 2006. Improving acceptance of computerized
prescribing alerts in ambulatory care. Journal of the American Medical Informatics
Association 13(1):5-11.
Shamliyan, T. A., S. Duval, J. Du, and R. L. Kane. 2008. Just what the doctor ordered. Review
of the evidence of the impact of computerized physician order entry system on medication
errors. Health Services Research 43(1 Pt 1):32-53.
Silver, J. D., and S. D. Hamill. 20111. Doctor, nurse disciplined by UPMC in kidney trans-
plant case. Post-Gazette.com. http://www.post-gazette.com/pg/11147/1149429-114-0.
stm#ixzz1amZZEw6Y (accessed October 14, 2011).
Singh, H., S. Mani, D. Espadas, N. Petersen, V. Franklin, and L. A. Petersen. 2009. Prescription
errors and outcomes related to inconsistent information transmitted through computer-
ized order entry: A prospective study. Archives of Internal Medicine 169(10):982-989.
Singh, H., E. J. Thomas, D. F. Sittig, L. Wilson, D. Espadas, M. M. Khan, and L. A. Petersen.
2010. Notification of abnormal lab test results in an electronic medical record: Do any
safety concerns remain? American Journal of Medicine 123(3):238-244.
Smith, D. H., N. Perrin, A. Feldstein, X. H. Yang, D. Kuang, S. R. Simon, D. F. Sittig, R. Platt,
and S. B. Soumerai. 2006. The impact of prescribing safety alerts for elderly persons in
an electronic medical record—an interrupted time series evaluation. Archives of Internal
Medicine 166(10):1098-1104.
Smith, L. B., L. Banner, D. Lozano, C. M. Olney, and B. Friedman. 2009. Connected care:
Reducing errors through automated vital signs data upload. Computers, Informatics,
Nursing 27(5):318-323.
Tierney, W. M., J. M. Overhage, M. D. Murray, L. E. Harris, X.-H. Zhou, G. J. Eckert, F. E.
Smith, N. Nienaber, C. J. McDonald, and F. D. Wolinsky. 2005. Can computer-generated
evidence-based care suggestions enhance evidence-based management of asthma and
chronic obstructive pulmonary disease? A randomized, controlled trial. Health Services
Research 40(2):477-497.
U.S. News. 2011. E-prescribing doesn't slash errors, study finds. U.S. News and World Report.
doesnt-slash-errors--study-finds (accessed October 14, 2011).
van der Sijs, H., A. Mulder, T. van Gelder, J. Aarts, M. Berg, and A. Vulto. 2009. Drug safety
alert generation and overriding in a large Dutch university medical centre. Pharmaco-
epidemiology and Drug Safety 18(10):941-947.
van der Sijs, H., T. van Gelder, A. Vulto, M. Berg, and J. Aarts. 2010. Understanding handling
of drug safety alerts: A simulation study. International Journal of Medical Informatics
Walsh, K. E., W. G. Adams, H. Bauchner, R. J. Vinci, J. B. Chessare, M. R. Cooper, P. M.
Hebert, E. G. Schainker, and C. P. Landrigan. 2006. Medication errors related to com-
puterized order entry for children. Pediatrics 118(5):1872-1879.
Weant, K. A., A. M. Cook, and J. A. Armitstead. 2007. Medication-error reporting and phar-
macy resident experience during implementation of computerized prescriber order entry.
American Journal of Health-System Pharmacy 64(5):526-530.
Whitley, H. P., J. D. Fermo, and E. C. G. Chumney. 2006. 5-year evaluation of electronic
medical record flag alerts for patients warranting secondary prevention of coronary heart
disease. Pharmacotherapy 26(5):682-688.
WHO (World Health Organization). 2008. World alliance for patient safety: Forward pro-
gramme 2008-2009. http://www.who.int/patientsafety/information_centre/reports/
Alliance_Forward_Programme_2008.pdf (accessed June 27, 2011).
WHO. 2011a. Patient safety: About us. http://www.who.int/patientsafety/about/en/index.html
(accessed June 25, 2011).
OCR for page 31
WHO. 2011b. WHO patient safety—programme areas. http://www.who.int/patientsafety/
about/programmes/en/index.html (accessed June 25, 2011).
Wolfstadt, J. I., J. H. Gurwitz, T. S. Field, M. Lee, S. Kalkar, W. Wu, and P. A. Rochon. 2008.
The effect of computerized physician order entry with clinical decision support on the
rates of adverse drug events: A systematic review. Journal of General Internal Medicine
Wright, A., J. Pang, J. C. Feblowitz, F. L. Maloney, A. R. Wilcox, H. Z. Ramelson, L. I.
Schneider, and D. W. Bates. 2011. A method and knowledge base for automated inference
of patient problems from structured data in an electronic medical record. Journal of the
American Medical Informatics Association 18(6):859-867.
Wright, M.-O. 2008. Automated surveillance and infection control: Toward a better tomorrow.
American Journal of Infection Control 36(3 Suppl 1):S1-S6.
Zhou, Y. Y., R. Unitan, J. J. Wang, T. Garrido, H. L. Chin, M. C. Turley, and L. Radler. 2011.
Improving population care with an integrated electronic panel support tool. Population
Health Management 14(1):3-9.
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3/3/2015 ARKANSAS TOURISM NOTICE: Arkansas's Seven Show Caves Are Open to the Public
In honor of Dr. Suess's birthday, join Park Interpreter BT to hear a Dr. Seuss classic, McElligot's Pool. Is there such a pool at Petit Jean State Park? "This pool might be bigger than you or I know!"
Petit Jean State Park 1285 Petit Jean Mountain Road Morrilton, AR 72110 Ph: (501) 727-5441 http://www.petitjeanstatepark.com email@example.com

subset: commoncrawl


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This semi-flushmount ceiling light is a great choice for an entry, hall and more.
Shaped like a melon, this elegant ceiling mount fixture from the Camden Collection will add a warm glow to any living space. It features a rich antique brass finish embellished with decorative etched metal details.
Customers most agreed on the following attributes:
This light creates a gorgeous starburst design when used with a clear lightbulb. It really showcases an area, making the ceiling very decorative, especially at night. Use of a dimmer switch gives the most options since it does put out a lot of light because of the clear glass (or use a lower wattage bulb). I highly recommend the light. I think it would look great in an entrace foyer, but mine is in a small hallway.
Starburst pattern
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I replaced a 35 year-old ceiling light in my back hall. I was limited to the height because of the backdoor and closet doors that swing into the space. This light is really nice, and throws lots of light (although I did prefer a frosted bulb). Really helps me see into the closet too which is lightless. Even my 20 year old grandson complimented me...'Nice light, gram; looks good. When did you get that?'. Now how many 20 year olds notice a back hall light? It must really look nice!
Our associates are standing by to assist you.


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A favorite on the Dugord farm in Normandy, this cake (which is really more of a pudding) wins with everyone. According to Isabelle Dugord, who convinced her grandmother to share the recipe, her family ate this all the time when she was growing up, and it's still her preferred sweet. Isabelle works part-time at a day-care center and always has the children make this at least once while they're with her. "It's easy to make, healthy, and they all, down to the last child, just love it," she said.
It can be served hot, lukewarm, or chilled, and is best the day it is made.
Raisins are traditional, though dates or figs are luscious, too.
YIELD: Makes 6 to 8 servings
1. Preheat the oven to 400°F (200 °C). Have ready a 6-cup (1 1/2 l) soufflé dish or charlotte mold.
2. Make the caramel: Place the 6 tablespoons sugar in a small heavy saucepan over medium heat. It will gradually dissolve, and as it does so, swirl it around in the pan. When it is a pale caramel color, after 4 to 5 minutes, quickly pour it into the mold, swirling the mold so the caramel completely covers the bottom. Use the pastry brush to brush the sides of the mold with the melted butter.
3. Whisk the eggs in a small bowl until they are blended and set aside.
4. Place the milk, 3/4 cup (150 g) sugar, and vanilla bean in a medium-size heavy saucepan. Stir, and heat over medium heat until the milk is steaming and small bubbles have formed around the edges. Immediately remove from the heat, cover and let infuse for 10 minutes. Then remove the vanilla bean, rinse it well, and reserve it for another use.
5. Return the milk to medium heat, and when small bubbles have formed around the edges, add the salt and the semolina, lightly sprinkling the semolina over the milk and stirring constantly. Continue to stir constantly as the semolina cooks (it will thicken dramatically), until it has become like a paste, at least 10 minutes.
6. Remove the semolina from the heat and whisk in the eggs until they are thoroughly combined. Then whisk in the nutmeg and stir in the raisins.
7. Pour the mixture into the prepared mold and bake in the center of the oven until the cake is puffed and golden, 45 minutes.
8. Remove the mold from the oven and let it cool for 10 minutes. Then unmold the cake onto a serving platter.
Excerpted from FRENCH FARMHOUSE COOKBOOK Copyright © 1996 by Susan Herrmann Loomis Used by permission of Workman Publishing, New York All Rights Reserved


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Weirauch, Anna Elisabet (1887-1970)
Anna Elisabet Weirauch is best remembered for her three-volume lesbian novel Der Skorpion (The Scorpion) set during the Weimar Republic. Born in Galatz, Rumania, Weirauch was moved, along with her sister, by her mother to Germany upon their father's death in 1891. By the turn of the century, they were living in Berlin, where Anna Elisabet studied acting. From 1906 to 1914, she was a member of Max Reinhardt's prestigious ensemble at the Deutsches Theater. Although she had written plays, she discovered after the war that her real talent lay in writing prose. Clearly, she had been writing for some time already since four novels and three novellas all appeared in 1919, the beginning of her long career. One of these was the first volume of Der Skorpion (The Scorpion), the work for which Weirauch is remembered today. This three-volume lesbian Entwicklungsroman (a novel that traces the development of its main character from childhood into young adulthood) follows Mette Rudloff from her troubled childhood, in search of love and of answers about her "different" sexuality, to her acceptance of her nature and the possibility that she can now find the love she has sought. The first volume portrays her from childhood through her early twenties. Olga, the first woman she loves, succumbs to the view of homosexual love as decadent and futile. After breaking off their relationship, she commits suicide. Mette's family hires a psychiatrist to "cure" her, but Mette refuses to accept a medical view of lesbians as aberrant and diseased. Over the course of the next two volumes, Mette experiences the lesbian and homosexual subcultures, mostly in Berlin, but never finds a home there. Each woman with whom she falls in love proves flawed, or scarred, by the outcast status of lesbians (and bisexuals) within this culture. Alcohol and drug use, promiscuity and psychological role-playing characterize the lives of most of the women she meets in Berlin's lesbian underground. By the end of the third novel, Mette has discarded the false choices of the metropolis--heterosexuality, suicide, "decadent" lesbianism--as being contrary to her nature. Having moved to the country, she learns to live alone and to accept herself. There, she realizes, she is ready to share her future with another woman. This work stands out from the multitude of fiction depicting lesbian or homosexual characters during the Weimar Republic. It does not apply a medical theory to the origin and appearance of same-sex love, nor does Weirauch deem it necessary to supply "scientific" evidence to defend her characters. These aspects explain the enormous resonance of this work. The first edition of the initial volume quickly sold out. Readers, especially lesbians, praised the novel's sympathetic and true-to-life depictions of lesbian characters. They begged Weirauch to tell more of Mette's story, a request she gladly granted. The novels have been translated into several languages. In English alone, they have had seven editions in various forms. Weirauch was gifted with a talent for writing prose and plots that afforded easy accessibility to and strong identification with readers. Her career spanned some of the most politically turbulent years in German history. Yet that reality makes only brief appearances in her stories. Much among her oeuvre can perhaps justly be labeled "trivial," but her trilogy Der Skorpion has found a secure place within the canon of literature that depicts homosexual characters with veracity and skill. |
Related Entries | |||||||||||||
literature >> Overview: German and Austrian Literature: Nineteenth and Twentieth Centuries |
Bibliography | ||
Foster, Jeannette H. Sex Variant Women in Literature. Tallahassee, Fla.: Naiad Press, 1985. Katz, Jonathan. Gay/Lesbian Almanac. New York: Harper and Row, 1983. Schoppmann, Claudia. Der Roman 'Der Skorpion' von Anna Elisabet Weirauch. Berlin: Frühlings Erwachen, 1986. |
Citation Information | ||||
Author: | Jones, James W. | |||
Entry Title: | Weirauch, Anna Elisabet | |||
General Editor: | Claude J. Summers | |||
Publication Name: | glbtq: An Encyclopedia of Gay, Lesbian,
Bisexual, Transgender, and Queer Culture |
Publication Date: | 2002 | |||
Date Last Updated | November 23, 2002 | |||
Web Address | www.glbtq.com/literature/weirauch_ae.html | |||
Publisher | glbtq, Inc. 1130 West Adams Chicago, IL 60607 |
Today's Date | ||||
Encyclopedia Copyright: | © 2002-2006, glbtq, Inc. | |||
Entry Copyright | © 1995, 2002 New England Publishing Associates |
This Entry Copyright © 1995, 2002 New England Publishing Associates www.glbtq.com
is produced by glbtq, Inc., 1130 West Adams Street, Chicago, IL
60607 glbtq™ and its logo are trademarks of glbtq, Inc. |


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Please confirm that the link referenced below is the one that is broken or needs to be updated. If confirmed, please complete the remaining boxes in the form below, then click on the button to send the update to us.
Title of the LinkThe Almanach de Saxe Gotha, Volume I, Page One, A Register of The Reigning Imperial and Royal Sovereign Houses of Europe
URL (address) for the Linkhttp://www.almanachdegotha.org


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Advice, Suggestions and General Help | New Topic | Printer Friendly Version |
It's not a matter of your being
Posted by: ezwater on Jul-09-13 4:11 AM (EST)
impressed. It's a matter of helping you to not repeat suburban legends. In this case, guideboat's imagining notwithstanding, Deliverance pumped up the cheap raft industry, but not canoeing.
You think I didn't know those guys personally? Seriously?
Dry Tops | Portage Carts/Carriers | Kindle / iPad Cases | Pro Coolers | Hoister |
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Danny O'Brien, who earned ACC rookie of the year honors after a breakout 2010 season, is on the verge of leaving Maryland's football program and transferring to another school, individuals with knowledge of the situation said Wednesday.
The departure of O'Brien, who has two years of eligibility remaining, would represent a significant blow to Coach Randy Edsall's program. If O'Brien departs, the Terrapins would have just one other experienced quarterback on the roster next season in junior-to-be C.J. Brown.


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You are hereSuperCooperators: Altruism, Evolution, and Why We Need Each Other to SucceedNew York: Free Press, 2011. 330 pages. Reviewer E. G. Leigh Jr. describes SuperCooperators as "a must for evolution teachers": "It emphasizes human cooperation more than the wonders of nature, but in today's world, that emphasis may make it a more effective teaching tool. Moreover, its message on cooperation's essential role in evolution and human affairs is right on target." Praising it for sounding "like an autobiographical fireside chat, in which Nowak celebrates his mentors … who helped him learn to shape mathematical questions about when cooperation evolves," Leigh faults it mildly for its occasional lack of clarity and for its deprecation of kin selection. |
NCSE T-shirts
Project Steve t-shirts can now be ordered online at the NCSE Store.
Voices for Evolution Staff Publications by Eugenie C. Scott edited by Eugenie C. Scott and Glenn Branch by Peter M. J. Hess and Paul L. Allen |


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{{ link.name }}NEW! SAVE BIG ON YOUR NEXT PROJECT WITH PREMIUM PACKS
US Secretary of State Hillary Clinton attends on June 5, 2012 a Coast... News PhotoAdult,Adults Only,Attending,Batumi,Ceremony,Coast Guard,Commercial Dock,Diplomacy,Georgia - Country,Harbor,Hillary Clinton,Horizontal,One Person,One Woman Only,Passenger,People,Politics,Secretary Of State,USAPhotographer SAUL LOEBCollection: AFP 2012 AFPUS Secretary of State Hillary Clinton attends on June 5, 2012 a Coast Guard ship commissioning ceremony at the passenger terminal wharf in Batumi. The Soviet-designed boat, which will patrol the eastern end of the Black Sea, was commissioned into the Georgian Coast Guard after a refurbishment with the latest technology, using funds provided by the US State Department Export Border Control and Related Security Program. AFP PHOTO / POOL / Saul LOEB (Photo credit should read SAUL LOEB/AFP/GettyImages)


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Posted on January 30, 2009 | 2
points, points, and more points are what we need!! post away!!
Posted on January 13, 2009 | 5
Less than 60 days to go till the phase 1 of the contest is over!! WE CAN DO IT!!!
Posted on January 8, 2009 | 4
Just wanted to say thank you to everyone that has been posting and participating in the zootoo.com contest for us!
We appreciate it very much!
Posted on December 17, 2008
If you guys are in the area of Padonia Station in Baltimore County, be sure and stop by! we will be there from 5 to 8 pm and we are hoping for a big turnout! Have a great night everyone and thank you for reading this note!
Posted on December 17, 2008
We went up to 7th yesterday, then fell back down to 8th...we need points!! I am hoping we can get back to 7th place...and here is one reason I rescue horses...this is Chief...pulled from New Holland last week. He is thoroughbred gelding, if you can b… more ›
Posted on November 22, 2008 | 1
Posted on November 18, 2008
Posted on November 13, 2008
I should have made a different post about the wild horses but please look at my previous post to read about that. Please post a comment in that forum in defense of America's wild horses.
Posted on November 13, 2008 | 1
Keep it going. Hey I just got an email about wild horses.
Please comment here: agriconenergy.blogspot.com/2008/11/reason-wild-horses-are-problem.html
I have 3 wild horses, they are wonderful. I've posted as SP111
Posted on November 13, 2008 | 2
YEA!!! We are now back up to 7th place...wow...you guys are fabulous!! WOO HOO! Thank you for your continued support...we truly appreciate it!!
Hugs to all!
Posted on November 3, 2008 | 1
Posted on November 2, 2008 | 3
C'mon Angel Acres, we're less than 200 points away from taking 7th place! Yeah, we can do this!!! Let's ZOOTOO everyone! WOOOHOOOO!!
Can't find a group you like? Create one and invite members!


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I was wondering how are the network interface statistics generated? Could someone point me out?
Take the 2-minute tour
Super User is a question and answer site for computer enthusiasts and power users. It's 100% free, no registration required.
The operating system kernel has to handle every network packet that flows in and out of the system and so it is a simple matter for the kernel to maintain counters and provide an API for other programs to display the statistics the kernel maintains. |


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The Rise of 'Speedtailing': The Drive for Fast, Flexible Online Ordering
Analyst Insight by Lamine Lahouasnia, Retailing Analyst at Euromonitor International
Already convinced that internet prices are the lowest, consumers are increasingly interested in the web as a source of greater convenience. Delivery locations and times have long been a barrier for consumers looking to purchase items online and many consumers revert back to store-based purchases if workplace/home deliveries are not viable options. Impulse items, in particular, underperform within the internet retailing channel due to the fact that long delivery times somewhat contradict the initial motivation of the purchase. This has prevented internet retailers from making much progress in higher margin impulse products such as toiletries.
Source: Euromonitor International
Note: Data taken from Euromonitor International's 'Out and About Survey'.
From buy now to collect nowWith internet retailing now accounting for 4% of global retail sales, the channel has become a familiar shopping venue for many consumers. However, whilst internet retailers have widened virtual aisles and lowered prices, they have struggled to recreate the feeling of instant gratification that consumers get from store-based shopping.
The solution appears to be quicker delivery options. Not satisfied with express next day delivery options, consumers have indicated a willingness to pay more for even quicker delivery times. This has resulted in a string of third party logistics companies such as Shutl, offering retailer to consumer delivery in less than one hour. Whilst not a complete substitute for the sense of gratification felt in-store, these services go a long way to replacing the need for store-based purchases.
Locker wars: Location, location, locationThe home or workplace has long been the default delivery options for internet retailers. However, consumers are now faced with a progressively diverse set of possibilities. Amazon, for example, has started to build its own network of delivery lockers in high footfall areas such as convenience stores and shopping centres. Google has also piqued a lot of interest from the retail community by buying a delivery locker start-up company. Of course, enlarging the range of delivery spots has long been of interest to homeshopping companies. German homeshopping specialist, Otto, has a significant retail network of third party stores which hold deliveries for consumers all over Germany.
One of the most interesting new concepts in this field is the deliver-to-car option pioneered by Belgian company, Cardrops. Rather than deliver to a fixed physical location, Cardrops delivers to a consumer's car, allowing delivery at any time regardless of where the consumer is. Whilst it is in its early stages, this could potentially be the next big thing in internet retailing.
By giving consumers more convenient delivery options as well as the feeling of instant gratification, speedtailing encourages consumers to shop for a wider range of items online. This can only be good news for internet retailers and delivery companies eager to continue taking market share from store-based retailers.
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Paizo Pathfinder® Paizo Games |
Pathfinder Tales: NightglassPaizo Publishing, LLC(based on 24 ratings)Show Description For: Non-Mint Add Print Edition: $9.99 Add PDF/ePub: $6.99
by Liane Merciel In the grim nation of Nidal, carefully chosen children are trained to practice dark magic, summoning forth creatures of horror and shadow for the greater glory of the Midnight Lord. Isiem is one such student, a promising young shadowcaller whose budding powers are the envy of his peers. Upon coming of age, he's dispatched on a diplomatic mission to the mountains of Devil's Perch, where he's meant to assist the armies of devil-worshiping Cheliax in clearing out a tribe of monstrous winged humanoids. Yet as the body count rises and Isiem comes face to face with the people he's exterminating, lines begin to blur, and the shadowcaller must ask himself who the real monsters are... From Liane Merciel, critically acclaimed author of The River King's Road and Heaven's Needle, comes a fantastical tale of darkness and redemption set in the award-winning world of the Pathfinder Roleplaying Game. 384-page mass market paperback ISBN–13: 978-1-60125-440-5 Download a free sample chapter by clicking here! (61 KB zip/PDF) Nightglass is sanctioned for use in Pathfinder Society Organized Play. Its Chronicle Sheet and additional are a free download (270 KB zip/PDF). Note: This product is part of the Pathfinder Tales Subscription. Product AvailabilityPrint Edition: Ships from our warehouse in 1 to 7 business days. PDF/ePub: Fulfilled immediately. Will be added to your My Downloads Page immediately upon purchase of PDF/ePub. Non-Mint: Ships from our warehouse in 1 to 7 business days. This product is non-mint. Refunds are not available for non-mint products. The standard version of this product can be found here. Are there errors or omissions in this product information? Got corrections? Let us know at firstname.lastname@example.com. PZO8509E See Also: |
News: Paizo is partnering with Tor for Pathfinder Tales Novels!,
Pathfinder Tales in Varisia,
Zae, Keren and Appleslayer are getting a novel :)))),
PTBC - Nightglass,
Lord of Runes Signing in Seattle,
PTBC - Nightblade,
Paizo Blog: The Gem,
The Plot Hole,
Paizo Blog: The Gem,
Radovan & the Count on HBO?,
Pathfinder RPG Designers Unleash Their Wildest Ideas to Play the Game Like Never Before,
Pathfinder Society and Syrinscape Join Forces for Epic Gaming Events at UK Games Expo,
New Strategy Guide for the Pathfinder Roleplaying Game Available Now!,
Monica Marlowe Wins RPG Superstar 2015 Game Design Competition,


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FISH Design
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This exquisite globe-shaped bowl is crafted of transparent strips bonded in overlapping colors.
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Wednesday, September 9, 2009
Did I show you my photos from Miami?
No, no -- wait. Sorry. I took these in East River Park looking over at the Edge and whatever that other stuff is.
2 comments:
- Goggla said...
A water taxi sure beats forking out for airfare. Save me some zinc oxide and a mai tai.
- September 9, 2009 at 10:37 AM
- EV Grieve said...
Why can't you ever seem to find a water taxi around 4 pm or when it's raining?
- September 9, 2009 at 11:07 AM
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Junior Member
Posts: 3
Karma: 62
Join Date: Apr 2012
Device: Kindle Touch
Browse any web site with Kindle Touch 3G
Moderator Notice Making use of this loophole is most likely against Amazon's TOS. Remember that the data going through your Kindle is tied to a unique ID, and that if you do this, Amazon is most likely going to know. You are going to take the risk of potentially bricking your device. This is not my idea... Credit goes to a Chinese guy called dgejal at bbs.duokan.com. I am just translating his post into English. I was actually debating if I should publicize this to a greater extent, given Amazon does watch... Well, here's how you can browse any web site over KT's 3G connection. 1. Go to Settings, Reading Options, Social Networks, make sure your don't have your Twitter account linked. Unlink it if you do. 2. Select Link Account under Twitter. 3. The Twitter login page will show up. Don't login here, instead, click the Twitter icon at upper left corner, it will bring you to the Twitter homepage. 4. Login with your Twitter account now. It won't go back to Kindle's Manage Your Social Networks page. 5. Send a tweet with the URL you wait to go. For instance, tweet "www.google.com" 6. Click on Home to force a refresh. You should see your last tweet now. 7. Click on the URL You are free now... One catch, some web site gave me 'Can not connect' error, not sure why. Have fun. Fine print: I hold zero responsibility on whatever action Amazon might take on your device... Last edited by Nate the great; 04-21-2012 at 08:51 PM. |
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So does anyone know if this works?
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it did not work for me. may be Amazon has fixed the hole by now.
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Teen's playground project earns acclaimWork at Buell Island leads to nomination for Eagle Scout of the Year awardApril 14, 2013LOWELL — It was nearly nine years ago that concern for a wheelchair-bound child's inability to join other youngsters on the playground at Lowell's Buell Island Park planted the seed of an idea in th...... BENLLOYDYou, Patrick are an amazing young man. Thinking of others, figuring out a way to help them, raising money for the project and following through. So many businesses could use your planning and implementation skills. 0 Agrees | 0 Disagrees | Report Abuse » Showing 1 of 1 comments
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Found soft spot on hull after putting on trailer
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Send along some photo's. The song chain in Off Topic is a good way to get your post count up. In the meantime, I wouldn't worry over much, it could be normal. Any chance this section of the hull was sitting on a boat stand or something before you got pounding around? And please take a look inside at the spot where it's soft and let us know what the construction of the boat looks like there. You'll probably want to pick up Don Casey's Complete Illustrated Guide to Sailboat Maintenance and start paging through it. It's about the best out there for the projects you're contemplating and worth every penny.
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Controlling the Obscurity
About this blog
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Friday, April 8, 2011
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(Montagu, 1803)Description (shell):Shell solid, cyrtoconoid, with stepped profile of six to seven slightly tumid, flat-shouldered whorls meeting at well-defined sutures. Sculpture of fine prosocline growth lines traversing spiral grooves and ridges. Umbilicus open and deep in young specimens, occluded by inner lip with age, and in larger shells appearing as an oval opening or small chink (G. tumida-drawing).Size:Up to 9 x 10 mm.Colour:Light fawn with broken brown bands across whorls; usually with greenish-blue iridescence.Animal:Body similar to Gibbula magus , snout not so papillate, sides of foot more so.Habitat:Sublittoral only; on Laminaria , and down to 1200 m on stones on sandy-muddy bottoms.Distribution:A northern species extending south from Iceland and north Norway to British, Irish, French, and Iberian coasts. Also found off Helgoland (Distr. G. tumida).
Kingdom AnimaliaPhylum MolluscaClass GastropodaSubclass ProsobranchiaSuperorder ArchaeogastropodaOrder VetigastropodaSuperfamily ScissurelloideaFamily TrochidaeGenus GibbulaSpecies Gibbula tumida
Status in World Register of Marine SpeciesAccepted name: Gibbula tumida (Montagu, 1803)
Scientific synonyms and common namesTrochus tumidus Montagu, 1803 Trochus patholatus Dillwyn, 1817 Gibbula tumida lusitanica Nordsieck, 1982
Graham, Alastair F.R.S., 1988. Molluscs: Prosobranch and Pyramidellid Gastropods. Synopses of the British fauna (NS), 2: 1-662.
Hayward, P.J., Wigham, G.D. & N. Yonow, 1990. Mollusca I: Polyplacophora, Scaphopoda, and Gastropoda. In: The Marine Fauna of the British Isles and North-West Europe. (ed. P.J. Hayward & J.S. Ryland). Clarendon Press, Oxford: 628-730.
Poppe, G.T. & Y. Goto, 1991. European Seashells. Vol. I. 352 pp. Wiesbaden/Verlag Christa Hemmen.
Seaward, D.R., 1990. Distribution of the marine molluscs of north west Europe. Nature Conservancy Council.
G. tumida-drawing Distr. G. tumida
No distribution map was available at OBIS the last time we checked. Retry now.
You can continue searching for Gibbula tumida on one of these Web sites:
Fauna Europaea (animals) | IOPI (plants) | NCBI (genetic)
Google | Yahoo | MSN | Wikipedia


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Home > Cambridgeshire > Swavesey
Lost Pubs In Swavesey, Cambridgeshire
Bird In Hand
Black Bull
Black Horse
Blue Bell
George & Dragon
Gibraltar Inn
Green Man
Little Rose
New Red Lion
Red Lion
Rising Sun
Rose & Crown
Sir Harry Smith
Six Days Only
Swan With Two Necks
Trinity Foot
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Please call 0844 879 8493 to speak to one of our advisors who will help you with your holiday needs.
The popular resort of Hammamet is situated along the north-east coast where you'll find stretches of sand and clear blue waters, a hotspot for watersports and relaxation. The town of Sousse is perfect if you want the old with the new, like the ancient walled medina set alongside modern cafés and restaurants.
Some of the best days and nights out are done on impulse, and we think that same spontaneity can be turned into a holiday. Browse through our late-deal destinations and become inspired to take a last-minute trip that won't break the bank. Our selection spans from a weekend retreat to a couple of weeks all inclusive in the sun, with a range of holidays and hotels to satisfy those wanting to take it easy on a package holiday or do it themselves with self-catering.
A last minute holiday is ideal for bargain-hunters, spontaneous friends, work-hard families, or those just longing for a break. Plenty of our last minute family holidays are just minutes from popular water and theme parks, making them great choices for the younger travellers (and the young at heart!) A late-deal holiday doesn't have to be sun, sea and sand. Surprise the other-half with a long weekend, city break to New York or Paris. The savings you make on the cost of the trip can be used to really take advantage of exploring a new city.
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Tokonatsu 2013
Event Information | |
Location | Boyd Campsite and Activity Centre, Henlow, Bedfordshire |
Start Date | Friday 30th August 2013 |
End Date | Monday 2nd September 2013 |
Website | www.tokonatsu.org.uk/home |
Event Description |
The Tokonatsu Camping Japanese Culture, Anime and Manga Festival is being held between Friday the 30th of August and Monday the 2nd of September 2013 in the beautiful setting of Bedfordshire, England. During your experience at Tokonatsu you will be pitching your tents along side fellow fans, enjoying the food, and entertainment provided. It is a unique festival within UK anime scene in which we all gather to discuss and enjoy Anime and Manga in the great outdoors. At Tokonatsu there will be a variety of events including Anime screenings, Masquerade, "The Quiz", DDR and the always popular Otaku Royal (both versions!). This year we celebrate the 10th year since the inception of the idea of Tokonatsu, and we hope to celebrate in style! We are expanding to include Japanese Culture on top of Anime and Manga, and we hope to bring a number of new stalls and ideas to the table. If you have any suggestions on additional ways we can celebrate this year, let us know! The festival is open to the ages of 13 and above, though under 16's will require parental consent before they can attend. |
Costumes | |||
Shinobu | 2x2 Shinobuden | FoxyChan | Complete |
Godot | Phoenix Wright: Trials and Tribulations | JaeXD | Complete |
Freyjadour Falenas | Suikoden V | silverwyn | Complete |