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Dangerous Dapsone.
Bookwalter T. AHRQ WebM&M [serial online]. June 2004.
A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly sevenfold overdose of dapsone.
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Commentary
Setting of Care
Outpatient Pharmacy
Target Audience
Health Care Providers
Non-Health Care Professionals
Clinical Area
Medical Oncology
Hospital Medicine
Hospital Pharmacy
Community Pharmacy
Safety Target
Side Effects/Adverse Drug Reactions
Ordering/Prescribing Errors
Transcription Errors
Dispensing Errors
Error Types
Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Approach to Improving Safety
Communication between Providers
Teamwork Training
Clinical Pharmacist Involvement
Computerized Provider Order Entry (CPOE)
Teamwork Training
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)