AHRQ Patient Safety Network

Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg.

ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.

This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.

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Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit.

Burmester MK, Dionne R, Thiagarajan RR, Laussen PC. Intensive Care Med. 2008;34:1083-1090.

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Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

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Another tragic parenteral nutrition compounding error.

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Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

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Resource Type

Newspaper/Magazine Article

Setting of Care

Intensive Care Units

Target Audience

Pharmacists

Clinical Area

Neonatology and Intensive Care

Pharmacy

Safety Target

Ordering/Prescribing Errors

Error Types

Active Errors

Latent Errors

Approach to Improving Safety

Credentialing, Licensure, and Discipline

Logistical Approaches

Computerized Adverse Event Detection

Education and Training

Origin/Sponsor

United States of America