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Approach to Improving Safety
Search results for "Active Errors"
- Active Errors
- Monitoring Errors and Failures
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Cases & Commentaries
Death by PCA
- Web M&M
Rodney W. Hicks, PhD, RN, FNP; February 2013
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Journal Article > Study
Electronic prescribing improves medication safety in community-based office practices.
Kaushal R, Kern LM, Barrón Y, Quaresimo J, Abramson EL. J Gen Intern Med. 2010;25:530-536.
Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.
Cases & Commentaries
Is the Admission Drug Dose Too Low?
- Web M&M
Rainu Kaushal, MD, MPH; Erika Abramson, MD ; August 2009
The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
Cases & Commentaries
Moving Pains
- Spotlight Case
- Web M&M
Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD; July 2006
An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
Cases & Commentaries
One ACE Too Many
- Web M&M
David N. Juurlink, BPhm, MD, PhD; July 2006
A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies.
Journal Article > Commentary
System errors in intrapartum electronic fetal monitoring: a case review.
Miller LA. J Midwifery Womens Health. 2005;50:507-516.
The author presents a case analysis to illustrate common system errors in the use of intrapartum electronic fetal monitoring: inadequate knowledge, fear of conflict, and poor communication.
Cases & Commentaries
Impatient Inpatient Dosing
- Spotlight Case
- Web M&M
Richard H. White, MD ; July-August 2005
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
Cases & Commentaries
Bleeding Risk
- Web M&M
Mark A. Crowther, MD, MSc; July 2003
Inadequate monitoring and management of warfarin places patient at significant risk of harm.