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Cases & Commentaries
- Web M&M
Saul N. Weingart, MD, PhD; August 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
Journal Article > Commentary
Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.
The authors outline the practical considerations in developing a medication patient safety program, including establishing a blame-free environment and collecting and analyzing error data.
Journal Article > Study
Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.
Pontefract SK, Hodson J, Marriott JF, Redwood S, Coleman JJ. PLoS One. 2016;11:e0160075.
Although electronic health records (EHRs) with computerized provider order entry are known to improve medication safety, experts have raised concerns that EHRs adversely affect interprofessional communication by reducing personal interactions among providers. This study examined unidirectional computerized messages from pharmacists and physicians within the EHR. Investigators found that less than half of messages from pharmacists were acknowledged by the prescribing physicians. Among the messages in which pharmacists requested a specific action, physicians completed the action about one-third of the time. Messages were more likely to be acknowledged and acted upon when pharmacists and physicians had an existing working relationship. The authors suggest that EHRs should be better designed to foster interprofessional collaboration. A PSNet perspective highlighted the role of pharmacists in interprofessional care and safety.