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Cases & Commentaries
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Robert J. Weber, PharmD, MS; February 2010
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
Journal Article > Study
Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.
Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.
The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.
Okemos, MI: Michigan Health & Hospital Association; October 2018.
This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. This year's achievements include avoidance of 6392 instances of harm and safety-related savings in the state of nearly $81 million. Areas of focus for improvement work included high reliability, sepsis reduction, and opioid stewardship. The report also summarizes results of the 15-year experience of the collaborative.
Journal Article > Study
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.