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Journal Article > Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.
The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed to an accidental morphine overdose. They discuss how the case illustrates that small mistakes can combine to create major problems.
Journal Article > Study
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.
Bowdle TA, Jelacic S, Nair B, et al. Br J Anaesth. 2018;121:1338-1345.
This pre–post study of errors in anesthesia compared self-reported errors before and after implementation of a medication safety bundle that included smart infusion devices and barcode medication administration. Wrong-medication errors declined after barcoding was introduced, consistent with prior studies.
Cases & Commentaries
- Web M&M
Tim Vanderveen, PharmD, MS; May 2009
Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.