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Cases & Commentaries
- Web M&M
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.
Beyzarov E. Drug Topics / Health-System Edition. September 18, 2006.
This article discusses the contamination and sterility issues inherent in the process of compounding drugs.
Dworkin A. The Oregonian. June 20, 2007:A01.
This article reports on dispensing errors made by Oregon pharmacists and the fines imposed as penalty for those errors.
Journal Article > Study
Garnerin P, Perneger T, Chopard P, et al. Anaesthesia. 2007;62:1090-1094.
Efforts toward standardization remain an important mechanism to address safety issues, such as with wristband use and drug labeling and package design. This study assessed the impact of different drug label information on injectable drug selection errors. Investigators provided three formats for conveying the concentration, quantity, and volume of a drug and evaluated the frequency of errors committed through a simulated exercise. They discovered significantly lower error rates with one of the formats in particular and call for regulatory bodies to implement standards on how such information should be displayed on injection drug labels.
Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.
This article reports that, despite facing state sanctions and fines for its role in three fatal medication errors since 2004, a violating hospital was slow to retrain its pharmacy technicians.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
Young A. The Atlanta Journal-Constitution; September 20, 2009:B1.
This newspaper article reports on numerous prescription mistakes in retail pharmacies in Georgia and offers tips for consumers to help prevent errors with their medications.
Journal Article > Study
Sharif I, Tse J. Pediatrics. 2010;125:960-965.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.
ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.
This newsletter piece discusses the pros and cons of physicians dispensing medications and its impact on patient safety.
LaGrone K. WPTV.com. April 30, 2012.
This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.
Suares W. FOX 25 KOKH-TV. July 30, 2014.
This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. June 30, 2015.
Standard use of metric oral dosage instructions has been advocated as a medication safety strategy. Raising concerns around dosing cups that include drams and ounces as scales—measures no longer in clinical use—which are available from major vendors and may be found in health care facilities, this announcement recommends use of oral syringes that only measure in milliliters for oral liquid medications to prevent errors.
Legislation/Regulation > Organizational Policy/Guidelines
Bethesda, MD: American Society of Health-System Pharmacists; 2016.
Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards development project, this report describes how standardization can improve reliability and safety of intravenous therapy and provides guidance on safe concentrations for drugs.