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Cases & Commentaries
- Web M&M
Audrey Lyndon, PhD, RN, and Stephanie Lim, MD; June 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
Journal Article > Study
Towards the reduction of medication errors in orthopedics and spinal surgery: outcomes using a pharmacist-led approach.
Weiner BK, Venarske J, Yu M, Mathis K. Spine. 2008;33:104-107.
This study describes the successful efforts of a pharmacist-led approach to reducing medication errors on a surgical specialty service. The approach included screening of orders and educational interventions.