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Discharge Fumbles.
Forster A. AHRQ WebM&M [serial online]. December 2004.
A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
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Resource Type
Commentary
Setting of Care
Hospitals
Emergency Departments
Target Audience
Health Care Providers
Clinical Area
Emergency Medicine
Hospital Medicine
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Medication Errors/Preventable Adverse Drug Events
Ordering/Prescribing Errors
Dispensing Errors
Look-Alike, Sound-Alike Drugs
Error Types
Epidemiology of Errors and Adverse Events
Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Latent Errors
Approach to Improving Safety
Communication between Providers
Health Literacy Improvement
Electronic Health Records
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)