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Cases & Commentaries
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William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Journal Article > Commentary
Karl RC. Bull Am Coll Surg. April 2007;92:16-22.
The author uses examples from his experience as a pilot to discuss aviation safety strategies, such as crew resource management, that can be applied to improve safety in surgery.