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Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
Journal Article > Study
Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Pediatr Crit Care Med. 2006;7:225-230.
This study demonstrated the effectiveness of a voluntary Web-based calculator as a mechanism to reduce errors in infusion ordering workflow. The authors describe the decision-support aspects of the system and their analysis of the data and errors abstracted from infusion orders.
Journal Article > Commentary
Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.
Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.
The authors suggest a model process utilizing failure mode and effects analysis to effectively implement emerging technologies that help minimize medication error.