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1 - 17 of 17
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.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-95.
This study found that 62% of patients transferred between units during a hospitalization had at least one unintentional medication discrepancy. The most common discrepancy was medication omission, independent of which system was used (e.g., paper versus computerized).
Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.
This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.
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.
Sentinel Event Alert. 2008;41:1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission. Note: This alert has been retired effective October 2019. Please refer to the full-text link below for further information.
Poon EG, Blumenfeld B, Hamann C, et al. Journal of the American Medical Informatics Association. 2006;13.
Prior studies have documented that medication errors frequently occur at times of transitions in care such as hospital admission and discharge. Hospitals are now required to have a system for medication reconciliation as a means of averting such errors. This article describes the development, pilot testing, and implementation of a medication reconciliation application within the electronic medical record (EMR) of an integrated health care network. At the time of hospital admission, the system integrates data from the outpatient and inpatient EMR to formulate an accurate medication list, which is used as the basis for medication reconciliation.

Healthc Q. 2006;9 Spec No:1-140.

This special issue describes projects and research in Canadian health care that are supporting improvements in patient safety.
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
A pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia.
Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.
After an admitting physician bases the dosages of medication on an outdated electronic medication list, the patient's heart nearly stops.