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- Communication Improvement 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Logistical Approaches 1
- Specialization of Care 1
- Clinical Information Systems 2
- Alert fatigue 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 2
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH; September 2011
Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Journal Article > Study
Oake N, Taljaard M, van Walraven C, Wilson K, Roth V, Forster AJ. Arch Intern Med. 2010;170:1804-1810.
Efforts to reduce the burden of disease caused by health care–associated infections have focused on specific infections that cause significant morbidity and mortality, such as central line–associated bloodstream infections and surgical site infections. Infection with Clostridium difficile (C. difficile), which causes severe diarrhea in patients receiving antibiotics for other reasons, has become increasingly common in hospitals as well. This Canadian study is the first to demonstrate a clear association between C. difficile infection and an increased risk of mortality. As these infections are considered largely preventable, the Center for Medicare and Medicaid Services no longer reimburses hospitals for additional costs associated with hospital-acquired C. difficile infection.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.