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hand-off error

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  • MaryW commented on the word hand-off error

    My mother endured a "hand-off" error following surgery for a nonmalignant brain tumor. Because physicians failed to order anti-seizure medication, she convulsed and entered a coma for three weeks, from which she emerged a hemiplegic with limited speech.
    James B. Lieber, Killer Care: How Medical Error Became America's Third Largest Cause of Death, and What Can Be Done About It (New York: OR Books, 2015), Introduction.

    My professional mentor . . .had a lung transplant at age 70. During the post-surgical hand-off, his attending physician ordered a necessary but highly toxic anti-rejection drug. A misplaced decimal point meant that my very sick colleague received ten times the intended dose. It killed him.
    Id.
    with shifts restricted to twenty-four hours there would be more hand-offs among doctors, sometimes with poor communications, and these situations were rife with the potential for error.
    Id., ch. 1.

    March 1, 2016