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Cases & Commentaries
Unexpected Drawbacks of Electronic Order Sets
- Web M&M
John D. McGreevey III, MD; November 2016
A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.
Cases & Commentaries
Lapse in Antibiotics Leads to Sepsis
- Web M&M
Mitchell Levy, MD; October 2016
Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.
Journal Article > Review
Identifying patients with sepsis on the hospital wards.
Bhattacharjee P, Edelson DP, Churpek MM. Chest. 2017;151:898-907.
Undiagnosed sepsis can lead to serious patient harm. This review describes proactive methods of monitoring patients to augment detection and early treatment of sepsis. The authors discuss how this process has evolved over time and suggest that automated tools can aid in identifying and managing sepsis.
Journal Article > Study
Clinical decision support for early recognition of sepsis.
Amland RC, Hahn-Cover KE. Am J Med Qual. 2016;31:103-110.
Sepsis is a clinical condition that can be rapidly fatal, thus prompt recognition and treatment is critical. This multicenter retrospective study describes the performance of a cloud-based computerized decision support system aimed at identifying sepsis in patients before infection was suspected.
Journal Article > Commentary
Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.
Upadhyay DK, Sittig DF, Singh H. Diagnosis (Berl). 2014;1:283.
Misdiagnosis and errors linked to electronic health records (EHRs) are common concerns in patient safety. This commentary examines these elements in the context of the first Ebola case in the United States to reveal weaknesses in emergency department care, disaster management, and diagnostic processes. The case analysis highlights challenges associated with forming diagnoses and the usability of EHRs as decision support tools.
Journal Article > Review
Automated and electronically assisted hand hygiene monitoring systems: a systematic review.
Ward MA, Schweizer ML, Polgreen PM, Gupta K, Reisinger HS, Perencevich EN. Am J Infect Control. 2014;42:472-478.
This systematic review evaluated new technologies for assisting hand hygiene monitoring, including automated counting systems, video monitoring, and fully automated monitoring systems. Currently, there is very limited data about how accurate, effective, and valuable these strategies are in enhancing hand hygiene compliance.
Journal Article > Study
Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert.
Micek ST, Heard KM, Gowan M, Kollef MH. Crit Care Med. 2014;42:1832-1838.
A decision support alert within an electronic medical record was able to identify patients with health care–associated infections (HAIs) who were being administered inappropriate antibiotic therapy. These findings suggest that clinical decision support systems can improve safety of antibiotic prescribing for intensive care unit patients with suspected HAIs.
Journal Article > Study
Effectiveness of an information technology intervention to improve prophylactic antibacterial use in the postoperative period.
Haynes K, Linkin DR, Fishman NO, et al. J Am Med Inform Assoc. 2011;18:164-168.
A standardized order set within a computerized provider order entry system improved appropriateness of antibiotics to prevent surgical site infections.
Cases & Commentaries
Mother's Milk, but Whose Mother?
- Web M&M
Dorothy Dougherty, RN; November 2010
A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
Journal Article > Commentary
ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.
This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.
Cases & Commentaries
EMR Entry Error: Not So Benign
- Web M&M
Ross Koppel, PhD; April 2009
A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
Journal Article > Study
Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention.
Di Pentima MC, Chan S, Eppes SC, Klein JD. Clin Pediatr (Phila). 2009;53:715-723e1.
A prescribing initiative built into an existing computerized provider order entry system successfully reduced antimicrobial prescribing errors at a children's hospital.