Hard to Swallow.
Driver J. AHRQ WebM&M [serial online]. October 2004.
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.
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Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
Recurrent Hypoglycemia: A Care Transition Failure?
Eytan T. AHRQ WebM&M [serial online]. October 2008.
Forster A. AHRQ WebM&M [serial online]. December 2004.
Multiple latent failures align to allow a serious drug interaction to harm a patient.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
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