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ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication errors.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2009;44:654-657.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.