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PSNet: Patient Safety Network
Newspaper/Magazine Article

Hidden medication loss when using a primary administration set for small-volume intermittent infusions.

ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).

Infusion misadministration is not always immediately evident. This story illustrates the problem of underdosing during infusions and suggests that unclear policies and lack of problem awareness contribute to the persistence of the mistake. The piece recommends education, use of data, and storytelling as tactics to reduce underdosing.