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Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Cohen MR. Hosp Pharm. 2008;43(4):257-260.
This monthly selection includes reports of a near miss when using a medication-reconciliation form as an order sheet, epidural tubing mistakenly utilized for an intravenous medication, a topical medication given orally, and problems with monitoring temperatures of medication refrigerators.