This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.
Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.
Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.
A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted.
Children's Hospital Colorado requires clinicians in all inpatient and outpatient facilities to confirm any order entered into its computerized order entry system through a popup verification screen that includes a prominent photograph of the patient, along with other key information such as age and gender. The goal is to capture the clinician's attention and force him or her to verify that the order has been entered into the correct patient's chart.