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Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
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.
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.