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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 pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia.
After an admitting physician bases the dosages of medication on an outdated electronic medication list, the patient's heart nearly stops.