Etchells E, Adhikari NKJ, Wu R, et al. BMJ Qual Saf. 2011;20:924-30.
In this study, clinicians were notified in real time about critical lab test abnormalities and provided with immediate decision support. However, this intervention did not prevent adverse events attributable to the critical test results, nor did it seem to result in more timely management.
Berner ES, Graber ML, eds. Adv Health Sci Educ Theory Pract. 2009;14(suppl 1):1-112.
This supplement consists of 12 articles drawn from a 2008 conference on diagnostic error, covering topics such as medical problem solving, clinical decision making, diagnostic decision support systems, and educational approaches to reducing diagnostic errors.
Lo HG, Matheny ME, Seger DL, et al. J Am Med Inform Assoc. 2009;16:66-71.
"Alert fatigue" refers to the tendency of clinicians to ignore safety alerts—for example, warnings about potential drug interactions—if alerts are too frequent or perceived to be clinically irrelevant. However, in this study, less intrusive alerts that did not require physician response were not effective at encouraging use of recommended laboratory monitoring.
Jen W-Y, Chao C-C. Int J Med Inform. 2008;77:689-97.
This study discovered that use of mobile patient safety information systems can contribute to improvement in services and a reduction in patient risk, but these communication systems may also contribute to physician anxiety.
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.