Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
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Sick and Pregnant
El-Ibiary S. AHRQ WebM&M [serial online]. November 2008.
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.
ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.
Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.
Abdel-Qader DH, Harper L, Cantrill JA, Tully MP. Drug Saf. 2010;33:1027-1044.
Impact of health information technology on detection of potential adverse drug events at the ordering stage.
Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.
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