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Lethal Cap.
Schillinger D. AHRQ WebM&M [serial online]. March 2004.
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
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Resource Type
Commentary
Setting of Care
Hospitals
Ambulatory Clinic or Office
Target Audience
Health Care Providers
Quality and Safety Professionals
Educators
Engineers
Patients
Clinical Area
Family Medicine
Primary Care
General Internal Medicine
Pediatrics
Community Pharmacy
Safety Target
Administration Errors
Error Types
Noncognitive Errors ("Slips & Lapses")
Approach to Improving Safety
Patient Self-Management
Health Literacy Improvement
Medical Device Design
Patient Education
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)