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Rockville, MD; Agency for Healthcare Research and Quality: April 2022.
Arnetz JE. Jt Comm J Qual Patient Saf. 2022;48(4):241-245.
Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022.
This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN: 9780309686259