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Journal Article > Study
Bates DW. Ann Intern Med. 2002;137:110-116.
This case study shares the experiences of a patient who suffered a medication error in receiving a dose of insulin inadvertently. The author reviews the epidemiology of medication errors and adverse drug events and shares a systems approach to medication errors, the role individuals and the system played in this particular case, and the potential prevention strategies to be considered. Finally, a comment about the institution's response to the event is presented to illustrate the importance of bridging what happens at the bedside with what needs to happen from the executive suite. This article is part of a collection entitled "Quality Grand Rounds," a series published in the Annals of Internal Medicine that explores quality issues and medical errors.
Journal Article > Commentary
McDonald CJ. Ann Intern Med. 2006;144:510-516.
This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.