WebM&M Cases & Commentaries
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- Dispensing Errors
- General Hospitals
- Interruptions and distractions
- Noncognitive Errors ("Slips & Lapses")
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.