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Derek C. Angus, MD, MPH; Eric B. Milbrandt, MD, MPH; July 2004
Following a motor vehicle collision, a patient is mistakenly given drotrecogin alfa (activated) for organ failure not due to sepsis.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. April 11, 2008;(39):1-5.
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these strategies is then assessed on Joint Commission site visits at health care organizations nationwide. This newly released Sentinel Event Alert focuses on pediatric medication errors, in light of recent data demonstrating that such errors are more common than previously thought and may not be prevented by standard medication error preventive measures. The alert highlights the importance of dosing errors (eg, weight-related and calculation-related errors), as well as the fact that technology used to reduce medication errors in adults must be adapted for children. A prior study documented the types of medication errors at an academic children's hospital and explored means of preventing such errors.