In this case report, the authors present an adverse event possibly caused by miscommunication among three separate medical teams at their hospital. The authors then discuss the hospital's root cause analysis and its proposed solutions, focusing on the subsequent hospital-wide implementation of an automated electronic reminder for abnormal laboratory values that may have helped to prevent similar medical errors.
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Funding This work was supported by internal funding supplied by the Department of Anesthesiology, University of Michigan.
Competing interests None.
Ethics approval Ethics approval was provided by University of Michigan IRB.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are no additional unpublished data; however, we would be happy to provide additional information about automated electronic laboratory reminders upon request.
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