A new journal article published this month becomes the latest to examine the potential pitfalls of IT in the healthcare system, examining a serious prescription error at New York Presbyterian. The authors reconstruct a series of mistakes affecting treatment of an elderly male patient experiencing kidney failure. Human error, poorly designed screens and a lack of warnings led to the mistake, which resulted in the patient receiving more than three times the maximum allowed dose of potassium. The CPOE was one developed internally at New York Presbyterian. The work is published in the July-August issue of the Journal of the American Medical Informatics Society.
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