An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Shah NR, Seger AC, Seger DL, et al. J Am Med Inform Assoc. 2006;13:5-11.
In this AHRQ-funded study, the investigators sought to increase acceptance of alerts by devising specific decision support for the ambulatory care setting, with only critical alerts interrupting clinician workflow.
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