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Patient death tied to lack of proper escalation process for barcode scanning failures.

ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.

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October 4, 2023

ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.

Lack of experience with distinct processes and products can lay the foundation for mistakes. This article examines an instance when a colonoscopy preparation product was switched with a dialysis fluid, a barcoding system didn’t recognize the substitution, and a patient died. Barcode identification, solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures contributing to harm.

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ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.

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