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Journal Article > Study
Jung B, Couldry R, Wilkinson S, Grauer D. Am J Health Syst Pharm. 2014;71:2153-2158.
This case study describes how the introduction of an electronic health record system at an academic medical center revealed that multiple dosing units could be ordered for some intravenous medications. For example, epinephrine could be ordered either as micrograms per minute or as micrograms per kilogram per minute. Following multiple stakeholder meetings and analyses, a strategy for standardization was adopted which led to decreased risks for medication errors.
Journal Article > Commentary
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
By introducing several scenarios that illustrate the effective use of a decision-making tree, the authors emphasize the importance of fair response to medication error at both the individual and system levels.
ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.
This article describes instances of tissue injury as a result of the misadministration of Promethazine and provides recommendations to minimize the risk of this occurring.