Narrow Results Clear All
- Communication Improvement 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Clinical Information Systems
Search results for ""
Cases & Commentaries
- Spotlight Case
- Web M&M
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.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Knox R. "All Things Considered." National Public Radio. July 20, 2006.
This story discusses findings from the 2006 Institute of Medicine report on medication errors and includes interviews with James Conway and Michael Cohen.
Journal Article > Study
Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial.
McGregor JC, Weekes E, Forrest GN, et al. J Am Med Inform Assoc. 2006;13:378-384.
Clinical decision support systems (CDSS) are being increasingly incorporated into electronic medical record systems. In this quasi-randomized study conducted at an academic medical center, the CDSS combined laboratory and pharmacy data to provide guidance on appropriate antimicrobial therapy to the hospital's antibiotic management team. The antibiotic management team made significantly more interventions on patients randomized to the intervention arm, resulting in cost savings for the hospital. The CDSS was also more efficient, saving the team nearly 1 hour per day. A prior systematic review revealed that CDSS have been broadly effective at changing provider behavior, but their effect on patient outcomes remains to be determined.
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.