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Cases & Commentaries
- Web M&M
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
Journal Article > Study
Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.
The researchers analyzed intralipid medication error reports submitted to the Medmarx database and found that most errors occur in the administration phase and often involve smart pump delivery systems or evening shift change.