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Search results for "Discontinuities, Gaps, and Hand-Off Problems"
Landro L. Wall Street Journal. June 7, 2011:D3.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Rifkin D. New York Times. November 16, 2009;Science Desk:5.
Reporting on cases of miscommunication and missed diagnosis, this news column illustrates how strictly following quality improvement procedures might lead providers to ignore important contextual information—from patients—that also contributes to safe care.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Brown D. Washington Post. April 10, 2007:HE01.
This article describes the Veterans Affairs' universal medical records network and illustrates how use of electronic medical records at VA medical centers supports safe care.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Cases & Commentaries
- Web M&M
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.