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Page: << Prev | 1 | 2 "A lot of them are examples of numbers being switched or a paper schedule that hadn't been updated," Wong said.
Although these misdirected pages did result in "delays and inefficiencies," the authors reported, they said it's not known if the mistakes actually resulted in patient harm.
The findings were much the same in both hospitals, even though each has different paging systems in place, suggesting that other hospitals might be experiencing similar woes.
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A previous study of 14,000 hospital admissions had found that communication problems in general trumped even medication errors as a source of preventable disability or death.
The researchers are now looking into why these mistakes occurred and have been making changes in hospital systems.
"We started to investigate how it was that nurses identified doctors to page them," Wong explained. "We realized that the process was not standardized. Some people would look in charts, some on the white board, so we centralized that information in one place -- in an online Web-based paging system."
Wong said it takes him about two hours a month to maintain the system.
Physicians are also now divided into four teams, with one person in each team being responsible for answering pages during a shift. The paging system is set up to contact that doctor at the given time.
"The nurses don't have to think of a doctor," he said. "They can go on the computer, type in "Team A" and one option shows up, whereas in the past they couldn't do that. In a way, it's making nurses think of physicians as a role instead of a person."
More information
The U.S. Agency for Healthcare Research and Quality has more on medical errors.
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