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Cases & Commentaries
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Patrice L. Spath, BA, RHIT; March 2007
An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.
Journal Article > Study
Matthews JI, Thomas PT. Int J Health Care Qual Assur. 2007;20:184-194.
The investigators interviewed clinicians and managers to assess how knowledge is captured in a clinical setting. They found that mechanistic reporting processes may compromise more organic methods of organizational learning.