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How a one-time bridging prescription became an every time refill

At what point, we have to ask ourselves, does a medical error that we do over and over again cease to be an error, and simply become business as usual?

At one of the patient safety conferences this week, where we reviewed sentinel events that occurred in the hospital and in the outpatient setting, one of the cases was about a patient who developed an abnormal cardiac rhythm as a result of drug interactions between several medicines he was taking, some prescribed in our practice, some from other providers.

The root cause analysis revealed multiple issues, several challenges, and eye-opening problems with how we are providing care, including the fact that a known drug-drug interaction did not set off an alert within the electronic health record, and a medication was listed for the patient as “no longer taking” although it turned out he was in fact still taking it.

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