Article Text

Download PDFPDF
Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis
  1. Robert E Freundlich1,
  2. Louise Grondin2,
  3. Kevin K Tremper1,
  4. Kelly A Saran3,
  5. Sachin Kheterpal1
  1. 1Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
  2. 2Department of Quality Improvement, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Office of Risk Management, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Robert Edward Freundlich, Department of Anesthesiology, 1H247 Box 0048, University of Michigan Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; freundli{at}


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.

  • Adverse events
  • epidemiology and detection
  • anaesthesia
  • quality improvement
  • root cause analysis
  • decision support
  • computerised
  • comparative effectiveness research
  • information technology

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • 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  • Data sharing statement There are no additional unpublished data; however, we would be happy to provide additional information about automated electronic laboratory reminders upon request.