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PSNet: Patient Safety Network
Journal Article

Implementation of standardized dosing units for I.V. medications.

Jung B, Couldry R, Wilkinson S, et al. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2014;71:2153-8.

This case study describes how the introduction of an electronic health record system at an academic medical center revealed that multiple dosing units could be ordered for some intravenous medications. For example, epinephrine could be ordered either as micrograms per minute or as micrograms per kilogram per minute. Following multiple stakeholder meetings and analyses, a strategy for standardization was adopted which led to decreased risks for medication errors.