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Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
McFadden C. ABC News Nightline. March 6, 2013.
Journal Article > Study
Grossman E, Phillips RS, Weingart SN. J Patient Saf. 2010;6:172-179.
Tests pending after hospital discharge or following a clinic visit continue to challenge most health care systems. This study implemented a paper-based system to follow up abnormal mammograms and monitored provider responses to those reminders. Based on a report of abnormal mammograms generated by the radiology department, a practice administrator sent a letter to each provider with a copy of the report and a set of questions on behalf of their quality improvement committee. More than 90% of providers responded to the fail-safe reminders, 8% were unaware of the abnormal test, and there was no follow-up plan in place for 3% of cases. Less experienced providers were more likely to be unaware of abnormal mammograms and many lapses were noted in the context of care transitions. The authors conclude that their paper-based system is feasible and valuable but requires full engagement of providers in the process.