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Misread Label.
Franklin BD. AHRQ WebM&M [serial online]. November 2003.
An infant born with sluggish breathing is given Lanoxin instead of naloxone and dies of digoxin toxicity.
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Resource Type
Commentary
Setting of Care
Labor and Delivery
Target Audience
Health Care Providers
Quality and Safety Professionals
Safety Scientists
Clinical Area
Pediatrics
Safety Target
Administration Errors
Look-Alike, Sound-Alike Drugs
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Approach to Improving Safety
Patient Disclosure
Communication between Providers
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)