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BMJ Qual Saf. 2012 Oct;21(10):850-4. Epub 2012 Jul 7.

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

Author information

  • 1Department of Anesthesiology, 1H247 Box 0048, University of Michigan Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA. freundli@med.umich.edu

Abstract

In this case report, the authors present an adverse event possibly caused by miscommunication among three separate medical teams at their hospital. The authors then discuss the hospital's root cause analysis and its proposed solutions, focusing on the subsequent hospital-wide implementation of an automated electronic reminder for abnormal laboratory values that may have helped to prevent similar medical errors.

PMID:
22773892
[PubMed - indexed for MEDLINE]
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