Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems

Schiff, Gordon D.; Aggarwal, Hem; Kumar, Sanjay; McNutt, Robert A.

doi:10.1016/s0002-9343(00)00546-5

Cited by 42 publications

(16 citation statements)

References 21 publications

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“…Other less obvious waste, occurring when patients do not receive their test, are the negative impact on Primary Care clinic access and efficiency when patients ask Primary Care to investigate those tests and find results for the patients. Also, when patients are not given their test results, they are less activated, generally experience lower levels of therapeutic adherence, and poorer outcomes [12,24]. …”

Section: Resultsmentioning

confidence: 99%

The frequency of missed test results and associated treatment delays in a highly computerized health system

Wahls

Cram

2007

BMC Fam Pract

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Section: Resultsmentioning

confidence: 99%

The frequency of missed test results and associated treatment delays in a highly computerized health system

Wahls

Cram

2007

BMC Fam Pract

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“…One reason that such clinical decision support is infrequently delivered is that today's subsystems – for example, the laboratory and pharmacy systems – do not have good interfaces and thus cannot readily communicate with each other. This lack of communication makes extracting important information and providing clinical decision support vastly more difficult than it needs to be [15,16]. …”

Section: Discussionmentioning

confidence: 99%

The quality case for information technology in healthcare

Bates

2002

BMC Med Inform Decis Mak

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BackgroundAs described in the Institute of Medicine's Crossing the Quality Chasm report, the quality of health care in the U.S. today leaves much to be desired.DiscussionOne major opportunity for improving quality relates to increasing the use of information technology, or IT. Health care organizations currently invest less in IT than in any other information-intensive industry, and not surprisingly current systems are relatively primitive, compared with industries such as banking or aviation. Nonetheless, a number of organizations have demonstrated that quality can be substantially improved in a variety of ways if IT use is increased in ways that improve care. Specifically, computerization of processes that are error-prone and computerized decision support may substantially improve both efficiency and quality, as well as dramatically facilitate quality measurement. This report discusses the current levels of IT and quality in health care, how quality improvement and management are currently done, the evidence that more IT might be helpful, a vision of the future, and the barriers to getting there.SummaryThis report suggests that there are five key policy domains that need to be addressed: standards, incentives, security and confidentiality, professional involvement, and research, with financial incentives representing the single most important lever.

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“…However, a child or confused patient may not give correct feedback, and in these situations nurses should check the patient's file to make sure the medication is prescribed for the right reason. Schiff et al (2000) identified hundreds of cases where hyperkalaemic patients were prescribed potassium supplements. The consequences of this were not examined in their study, but cardiac arrest is a possible outcome.…”

Section: Right Actionmentioning

confidence: 99%

The nine rights of medication administration: an overview

2010

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Nurses are responsible for ensuring safety and quality of patient care at all times. Many nursing tasks involve a degree of risk, and medication administration arguably carries the greatest risk. Unfortunately, patients are frequently harmed or injured by medication errors. Some suffer permanent disability and for others the errors are fatal. Nurses have traditionally followed the five rights of medication administration (patient, drug, route, time, dose) to help prevent errors, and more recently, the seven rights (including documentation and reason). This article identifies nine rights of medication administration.

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Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems

Cited by 42 publications

References 21 publications

The frequency of missed test results and associated treatment delays in a highly computerized health system

The frequency of missed test results and associated treatment delays in a highly computerized health system

The quality case for information technology in healthcare

The nine rights of medication administration: an overview

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