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The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.
Coffey SB. American Nurse Journal. Epub March 2, 2023.
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4.
ISMP Medication Safety Alert! Acute care edition. January 26, 2023:28(2):1-4.
A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.
ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.