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Eptifibatide Epilogue AHRQ WebM&M icon
Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
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