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On the Other Hand
Henneman EA. AHRQ WebM&M [serial online]. May 2007.
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
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Commentary
Setting of Care
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Health Care Providers
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Discontinuities, Gaps, and Hand-Off Problems
Medication Errors/Preventable Adverse Drug Events
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Cognitive Errors ("Mistakes")
Approach to Improving Safety
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Clinical Information Systems