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Glance LG, Dick AW, Osler TM, et al. Arch Surg. 2011;146:1170-7.
The Leapfrog Group, a consortium of public and private employers who purchase health care for more than 30 million Americans, strives to improve patient safety through encouraging hospitals to implement the National Quality Forum's safe practices and 3 other key safety interventions (including computerized provider order entry). More than 1200 hospitals nationwide have joined the Leapfrog Group's effort to date. However, this analysis of hospital-level trauma outcomes found essentially no relationship between adoption of the Leapfrog interventions and outcomes for trauma patients. This study's results mirror the findings of a prior study that found no improvement in mortality at Leapfrog hospitals for a broad range of inpatient diagnoses.
A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.
Washington, DC: Leapfrog Group; December 4, 2009.
This news announcement highlights the 45 urban, children's, and rural hospitals recognized for highly efficient performance and continuous improvement in patient safety based on the 2009 Leapfrog Hospital Survey results.
Griffey RT, Wittels K, Gilboy N, et al. Ann Emerg Med. 2009;53:469-76.
Computerized reminders to renew orders for physical restraints were combined with a forcing function—denial of computer access until the order was completed—in this trial conducted in an emergency department. Although clinician ordering behavior improved, no significant improvement was found in the amount of time patients spent in restraints.
Cohen MR.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.

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.
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.