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PSNet: Patient Safety Network
Journal Article

Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose.

Just S, Schepers G, Piotrowski MM, et al. Joint Commission journal on quality and patient safety. 2006;32:366-72.

The authors share lessons learned from reviewing an adverse event with a rarely used medication and provide five recommendations to prevent similar incidents.