Issue 2
Gaps in Interconnectivity of a Hospital’s Electronic Systems Create Vulnerabilities at Transitions of Care
This bulletin explores a case of a morphine overdose during a transition of care between 2 hospitals. The error was a result of a discrepancy created by an electronic medication system that did not communicate in real time.
Key Words:
- Integrated systems
- Communication gap
- Medication Administration Record (MAR)
- Discharge prescription
- Automation complacency
- Medication reconciliation
๐ฆ๐ถ๐ฑ๐ฒ๐ฏ๐ฎ๐ฟ๐:
- Cannabis for Medical Use โ Submit Your Incidents and Concerns
- Education to Support Mandatory ADR/MDI Reporting (Vanessaโs Law)