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Newspaper/Magazine Article
Patient death after inadvertent infusion of PRN medication hanging on bedside intravenous (IV) pole.
May 1, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(8):1-4.
A multitude of latent and active failures typically contribute to harmful medication errors in hospitals. This article examines a prolonged intravenous medication administration error and describes “holes in the Swiss cheese” that enabled the failure. Recommendations for improvement discussed in this article include daily review of medications, look-alike medication management, and infusion line verification.
