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Miscalculated Risk
Strassels SA. AHRQ WebM&M [serial online]. August 2006.
In anticipation of discharge, a patient's opiate medication is changed from an immediate-release to a long-acting form—but the dose was incorrectly converted, resulting in an overdose. The patient develops respiratory distress and requires a 2-week stay in the ICU.
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Weber RJ. AHRQ WebM&M [serial online]. May 2006.
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Resource Type
Commentary
Setting of Care
General Hospitals
Target Audience
Physicians
Nurses
Pharmacists
Risk Managers
Quality and Safety Professionals
Clinical Area
Hospital Medicine
Safety Target
Ordering/Prescribing Errors
Administration Errors
Look-Alike, Sound-Alike Drugs
Opiates/Narcotics
Error Types
Active Errors
Approach to Improving Safety
Practice Guidelines
Computerized Provider Order Entry (CPOE)