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	Search Advanced Search < Back  Email to a colleague Please don't sleep through this wake-up call. ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.   This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error that occurred because of a misinterpreted decimal point. The error involved administration of morphine to a 9-month-old infant who received 5 mg instead of 0.5 mg of the drug. The order did not include a zero before the decimal point, and the nurse filling the order overlooked the omission. The child suffered a cardiac arrest and died. The case illustrates the importance of clearly communicating information about medications.    Free full text   Resource Type:    Newspaper/Magazine Article Target Audience:    Health Care Providers      Health Care Executives and Administrators      Non-Health Care Professionals Safety Target:    Medication Safety > Medication Errors/Preventable Adverse Drug Events > Transcription Errors      Medication Safety > Medication Errors/Preventable Adverse Drug Events > Administration Errors Error Types:    Active Errors Approach to Improving Safety:    Quality Improvement Strategies > Practice Guidelines Origin/Sponsor:    North America > United States of America Produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Editorial Board. This site was designed and implemented by Silverchair. Contact AHRQ PSNet | Copyright | AHRQ PSNet Privacy Policy | Terms & Conditions | Help
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