Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg.
Approach to Improving Safety
- Credentialing, Licensure, and Discipline
- Logistical Approaches
- Computerized Adverse Event Detection
- Education and Training
Setting of Care
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.