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Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
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.
Perspectives on Safety > Perspective
with commentary by Christopher Nemeth, PhD, Unintended Consequences, June 2011
This piece discusses how adopting new technology can have unintended effects.
Journal Article > Commentary
Bates DW, Wachter RM, Vanderveen T. Patient Saf Qual Healthc. July/August 2009;6:22-27.
This piece shares insights from an interactive audio conference regarding the potential impact of information technology on safe medication delivery.
Journal Article > Study
Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.