Narrow Results Clear All
- Culture of Safety 1
- Education and Training 1
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Teamwork 1
- Technologic Approaches
Search results for ""
Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Journal Article > Commentary
McDonald CJ. Ann Intern Med. 2006;144:510-516.
This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.
Journal Article > Study
Wright L, Feldott CC, Hargrove FR. Hosp Pharm. 2007;42:158–161.