Copy and Paste
Hersh W. AHRQ WebM&M [serial online]. July 2007.
A hospitalized elderly woman had clinical indications to receive medication to prevent venous thromboembolism. The intern noted this in the electronic record, and although this information was copied and pasted in the record on 4 consecutive days, the patient never received the intended prophylaxis and suffered a pulmonary embolism after discharge.
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Electronic alerts to prevent venous thromboembolism among hospitalized patients.
Kucher N, Koo S, Quiroz R, et al. N Engl J Med. 2005;352:969-977.
Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.
Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.
Time to sign off on signout.
Stein DM, Stetson PD. Acad Med. 2011;86:804-806.
As industry automates, adverse events continue to haunt caregivers.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
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Setting of Care
Venous Thrombosis and Thromboembolism
Noncognitive Errors ("Slips & Lapses")
Approach to Improving Safety
Computerized Decision Support
Electronic Health Records
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