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Commentary

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

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October 28, 2009
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.

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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.