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.
A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.