Steven J. Spear, DBA, MS, MS; Mark Schmidhofer, MD, MS
Acknowledgments: The authors thank Dr. Frank Davidoff and Mr. John Elder for their substantial contributions to earlier drafts of this manuscript.
Grant Support: By the Harvard Business School Division of Research.
Potential Financial Conflicts of Interest: Consultancies: S.J. Spear (for industrial and health care organizations with respect to implementing a management process similar to the Toyota Production System); M. Schmidhofer (principal with True North Institute, Inc., which provides consulting services to organizations seeking to implement processes similar to the Toyota Production System).
Requests for Single Reprints: Steven J. Spear, DBA, MS, MS, Harvard Business School, Morgan Hall T13, Boston, MA 02163; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Spear: Harvard Business School, Morgan Hall T13, Boston MA 02163.
Dr. Schmidhofer: Cardiovascular Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, F 350.2, Pittsburgh, PA 15213.
Spear S., Schmidhofer M.; Ambiguity and Workarounds as Contributors to Medical Error. Ann Intern Med. 2005;142:627-630. doi: 10.7326/0003-4819-142-8-200504190-00011
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Published: Ann Intern Med. 2005;142(8):627-630.
The Quality Grand Rounds series in Annals illustrates how work-system conditions can produce errors and adverse events (1). The human cost of medical error provided incentive for such studies (2-5).
In one case, a nurse mistakenly used insulin rather than heparin to flush the arterial line of a patient, Mrs. Grant, causing severe hypoglycemia, seizures, coma, and, ultimately, death (6). In another, unreliable processes for identifying patients, assuring consent, and exchanging information led to a Mrs. Morris being mistaken for a Mrs. Morrison; as a result the patient was subjected to an unnecessary, potentially dangerous electrophysiologic examination (7).
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Cardiology, Endocrine and Metabolism, Hospital Medicine, Diabetes, Coronary Risk Factors.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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