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PSNet: Patient Safety Network
Journal Article

Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error

Meisenberg B, Zaidi S, Franks L, et al. Journal of hospital medicine. 2019;14:716-718.

Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors.