Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose.
Just S, Schepers G, Piotrowski MM, et al. Improving the safety of intravenous admixtures: lessons learned from a Pentostam overdose. Jt Comm J Qual Patient Saf. 2006;32(7):366-72.
The authors share lessons learned from reviewing an adverse event with a rarely used medication and provide five recommendations to prevent similar incidents.

