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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
Gordon MB, Melvin P, Graham D, et al. Arch Pediatr Adolesc Med. 2011;165:424-428.
Improving teamwork and communication is a continued focus in the hospital setting. Targeted interventions to address noted gaps include adoption of interdisciplinary rounds, use of patient whiteboards, and structured tools such as SBAR. This study reorganized physicians into unit-based teams to evaluate the impact on nurse–physician communication. Following implementation of the new model, physicians were more likely to identify the nurse for their patients and experience increased frequency of direct communication with them. These changes also led to 42% fewer pages from nurses to physicians. While the study didn't correlate these self-reported improvements in communication to clinical outcomes, it's one of the first studies investigating the benefits of geographic organization as a potential safety strategy.