8. Abnormal cardiac ultrasound results misrouted, would have prompted anticoagulation; patient died of stroke.System dysfunction or malfunction
not be completed, resulting in an injurious medication error.
kept ‘crashing’; delayed recognition of patient’s deterioration.
results filed without the MD seeing these, staff believing the
results were available on line.
with the delivery room system. Covering MD delivered
the baby but did not know\see the request for tubal
ligation; Patient became pregnant 6 months later.
Lack of or failure of Alert/Alarm/Decision Support
to patient’s physician; delayed diagnosis of cancer.
until patient’s visit a year later.
order by mistake.
was too small; entry noted only as “epigastric pain”; no
ECG done; patient experienced a cardiac event days later.
problems by a number, not text.
wrong patient; real patient died of cancer 3 years later, original
report was abnormal.
and did not interface with the inpatient unit.
the incomplete exam; patient had delayed diagnosis of colon
not uploaded into the EHR.
31. Facility with new EHR dosage of Benemid copied over from paper record incorrectly; patient received double doses, developed
seizures and died.
clicked on “continue Lovenox for home use”.\\
33. Ultrasound results never scanned into the EHR; delayed diagnosis of thyroid malignancy.
Prepopulating; copy and paste
38. Covering obstetrician did not have EHR access and could not access clinic notes documenting abnormal fetal size; stated he\she never received training or password.
40. Amoxicillin ordered for patient allergic to penicillin had allergic reaction; MD over-rode the alert.