When clinical staff at a MedStar Health hospital near Washington misunderstood a confusing pop-up box on a digital blood-sugar reader in 2011, they mistakenly gave insulin to a patient with low blood sugar, which caused her to go into a diabetic coma. Hospital staff had earlier made a seemingly minor customization to the glucometer, which led to the error.
In 2013, a patient admitted to Northwest Community Hospital in Arlington Heights, Ill., did not receive his previously prescribed psychiatric medicine for nearly three weeks during a hospital stay because the pharmacy's computer system was programmed to automatically discontinue orders for certain types of drugs after a predetermined time. There was no alert programmed into the system to let the patient's care team know the drug order had been suspended.
Source: Modern HealthCare
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