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Spath PL. AHRQ WebM&M [serial online]. March 2007.

An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.

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Resource Type

Commentary

Setting of Care

Hospitals

Target Audience

Health Care Providers

Health Care Executives and Administrators

Clinical Area

Safety Target

Look-Alike, Sound-Alike Drugs

Error Types

Epidemiology of Errors and Adverse Events

Latent Errors

Approach to Improving Safety

Error Reporting

Error Analysis

Communication between Providers

Human Factors Engineering

Learning Organization