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Cases & Commentaries
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Saul N. Weingart, MD, PhD; August 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
Journal Article > Study
Is the test result correct? A questionnaire study of blood collection practices in primary health care.
Söderberg J, Wallin O, Grankvist K, Brulin C. J Eval Clin Pract. 2010;16:707-711.
This study in Swedish primary care clinics revealed that recommended practices to prevent identification errors, such as using two different identification modalities, were not routinely used.