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; 2013.
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.
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