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Staggers N, Clark L, Blaz JW, et al. Health Informatics J. 2011;17:209-23.
By enhancing providers' ability to transmit information in a concise and standardized fashion, electronic medical records (EMR) offer great promise for improving handoffs and signouts. However, this analysis of nursing handoffs at an institution with a commercial EMR found that the built-in patient summaries provided inadequate detail and flexibility for clinical signout purposes, forcing nurses to develop workarounds for transmitting key information. This finding reveals the importance of human factors engineering in designing information technology solutions for patient safety problems.
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.
A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.
After an admitting physician bases the dosages of medication on an outdated electronic medication list, the patient's heart nearly stops.