I'm happy to say that I'm writing this post from the happy land of looking at the big picture. My reasons for writing were not because I actually had this happen to me, or in my workplace. Rather, I'm presenting this as a something to think about while you're working.
First, no one is infallible. Second, computers are great, but they can't critically think. Three, this could happen to anyone.
Here are a couple of articles from the blogosphere about near misses.
Paul Levy from Running a Hospital in Boston blogged about near misses in this blog post.
Florence dot com blogged about her own Coumadin experience in this Nurses' Week article.
An oldie but goodie related article: Health Care Renewal talks about workarounds in bar coded medication administration systems.
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