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A Mid-Summer Fog
Braddock CH. AHRQ WebM&M [serial online]. November 2008.
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Quality and Safety Professionals
Information Professionals
Educators
Clinical Area
Gynecology
Safety Target
Medication Errors/Preventable Adverse Drug Events
Insulin
Error Types
Active Errors
Approach to Improving Safety
Audit and Feedback
Benchmarking
Critical Pathways
Teamwork Training
Computerized Provider Order Entry (CPOE)
Computerized Decision Support
Residents and Fellows
Simulators