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Cases & Commentaries
- Web M&M
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 > Study
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Sard BE, Walsh KE, Doros G, et al. Pediatrics. 2008;122:782-787.
Standardizing care processes, through the use of checklists and other approaches, has been demonstrated to improve patient safety by reducing health care–associated infections and handoff errors. This study implemented a standardized "quicklist" of commonly used pediatric medications within an existing computerized provider order entry system. Although use of the quicklist was not mandatory, prescribing errors were significantly reduced, especially among those providers who used the quicklist regularly. The study provides an example of how standardization combined with decision support can improve medication safety.