How a series of errors led to recurrent hypoglycemia

Journal of Family Practice

Volumn 55, Issue 6, 2006, Pages 489-497

  Singh, Ranjit ^a,b  

^a UNIVERSITY AT BUFFALO   (United States)

^b Clinical Center   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ALLOPURINOL; ATORVASTATIN; CARISOPRODOL; CELECOXIB; CLOPIDOGREL; ENALAPRIL; GLIPIZIDE; GLUCOSE; HYDROCODONE; SILDENAFIL;

ADULT; CASE REPORT; CLINICAL FEATURE; DROWSINESS; EMERGENCY TREATMENT; FAMILY MEDICINE; GLUCOSE BLOOD LEVEL; GOUT; HUMAN; HYPERTENSION; HYPOGLYCEMIA; MALE; MEDICATION ERROR; NON INSULIN DEPENDENT DIABETES MELLITUS; PATIENT MONITORING; POSTTRAUMATIC STRESS DISORDER; PROSTATE CANCER; PROSTATECTOMY; REVIEW; SLURRED SPEECH; SWEATING; SYNCOPE; VIET NAM;

COMMUNICATION; GLIPIZIDE; HUMANS; HYPOGLYCEMIA; HYPOGLYCEMIC AGENTS; MALE; MEDICATION ERRORS; MIDDLE AGED; RECURRENCE;

EID: 33745153433     PISSN: 00943509     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (26)

1. Schmader K, Hanlon JT, Weinberger M, et al. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994; 42:1241-1247.
2. Tamblyn R, Huang A, Perreault R, et al. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. CMAJ 2003; 169:549-556.
3. Schmidt I, Claesson CB, Westerholm B, Nilsson LG, Svarstad BL. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc 1998; 46:77-82.
4. Meredith S, Feldman P, Frey D, et al. Improving medication use in newly admitted home healthcare patients: a randomized controlled trial. J Am Geriatr Soc 2002; 50:1484-1491.
5. Joint Commission on Accreditation of Healthcare Organizations. 2006 Joint Commission National Patient Safety Goals. Available at: www.jcipatientsafety. org. Accessed on May 4, 2006.
6. Barnsteiner JH. Medication reconciliation: transfer of medication information across settings-keeping it free from error. J Infus Nurs 2005; 28(2 Suppl):31-36.
7. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual 2005; 20:95-98.
8. Pronovost P, Weast B, Schwarz M, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care 2003; 18:201-205.
9. Atkin PA, Finnegan TP, Ogle SJ, Shenfield GM. Are medication record cards useful? Med J Aust 1995; 162:300-301.
10. Atkin PA, Stringer RS, Duffy JB, et al. The influence of information provided by patients on the accuracy of medication records. Med J Aust 1998; 169:85-88.
11. Whyte LA. Medication cards for elderly people: a study. Nurs Sfand 1994; 8(48):25-28.
12. Yang Y, Han X, Bao F, Deng RH. A smart-card-enabled privacy preserving E-prescription system. IEEE Trans Inf Technol Biomed 2004; 8:47-58.
13. Naszlady A, Naszlady J. Patient health record on a smart card. International Journal of Medical Informatics. Int J Med Inform 1998; 48:191-194.
14. Auber BA, Hamel G. Adoption of smart cards in the medical sector. the Canadian experience. Soc Sci Med 2001; 53:879-894.
15. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003; 289:1001-1007.
16. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? Asurvey of internal medicine patients in an academic setting. Arch Intern Med 1996; 156:2565-2569.
17. Mazor KM, Simon SR, Yood RA, et al. Health plan members' views about disclosure of medical errors. Ann Intern Med 2004; 140:409-418.
18. Schwappach DL, Koeck CM. What makes an error unacceptable? A factorial survey on the disclosure of medical errors. Int J Qual Health Care 2004; 16:317-326.
19. Finkelstein D, Wu AW, Holtzman NA, Smith MK. When a physician harms a patient by a medical error ethical, legal, and risk-management considerations. J Clin Ethics 1997; 8:330-335.
20. Wu AW Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997; 12:770-775.
21. Mazor KMS, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med 2004; 164:1690-1697.
22. Reason J. Human Error. New York, NY: Cambridge University Press; 1990.
23. Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ 2005; 39:1195-1204.
24. Kohn LT, Corrigan J, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
25. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002; 287:487-494.
26. Rooney WR. Maintaining a medication list in the chart. Fam Pract Management 2003; 10:52-54.