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Journal Article > Study
Wright A, Ai A, Ash J, et al. J Am Med Inform Assoc. 2018;25:496-506.
Clinical decision support (CDS) includes electronic alerts that can prevent errors. Excessive or erroneous alerts may lead to alert fatigue or other unintended consequences. Researchers used a blend of qualitative methods such as interviews and quantitative data like alert rates to develop a taxonomy of CDS alert errors. The taxonomy includes the origin of the error, which most commonly occurred with introduction of a new decision support rule, and describes the underlying reason for the error, such as problems with new terms, conceptualization, and building the rule as intended. Errors could cause an alert to fail to appear for a relevant situation or could cause an irrelevant or erroneous alert to appear. Most errors came to light through reports from users. The authors recommend classifying CDS alert errors using this taxonomy so that safety efforts will be consistent and actionable.
Cases & Commentaries
- Web M&M
Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017
A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
Journal Article > Study
NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.
Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.
Medication errors are common in neonatal intensive care unit (NICU) settings. This study used data from MEDMARX, a voluntary reporting system for medication errors, to analyze the underlying causes of adverse drug events in the NICU. While most errors did not cause patient harm, prescribing errors, errors involving malfunctioning equipment, and errors associated with known high-risk medications were more likely to cause clinical consequences. Most errors were ascribed to human factors causes. While prior research has found that computerized provider order entry (CPOE) can reduce medication errors in the NICU, it is notable that nearly half the reported errors in this study occurred during medication administration, and therefore would not have been prevented by CPOE.