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
Flores G. AHRQ WebM&M [serial online]. April 2006.
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2011.
Development of an expert system for classification of medical errors.
Kopec D, Levy K, Kabir M, Reinharth D, Shagas G. Stud Health Technol Inform. 2005;114:110-116.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:844-847.
View all related resources...
Find Related Resources by...
Health Care Providers
Health Care Executives and Administrators
Non-Health Care Professionals
Approach to Improving Safety
United States of America
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ PSNet site was designed and implemented by Silverchair.
Contact AHRQ PSNet
Terms & Conditions
Freedom of Information Act
The White House
USA.gov: U.S. Government Official Web Portal
Agency for Healthcare Research and Quality • 540 Gaither Road Rockville, MD 20850 • Telephone: (301) 427-1364