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Citrate Mix-Up
Weber RJ. AHRQ WebM&M [serial online]. May 2006.
A pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia.
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Physicians
Nurses
Pharmacists
Risk Managers
Clinical Area
Pharmacy
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Dispensing Errors
Look-Alike, Sound-Alike Drugs
Error Types
Cognitive Errors ("Mistakes")
Latent Errors
Approach to Improving Safety
Practice Guidelines
Reminders
Bar Coding and Radiofrequency ID Tagging
Computerized Provider Order Entry (CPOE)
Computerized Decision Support
Medication Reconciliation