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ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.
This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.
Journal Article > Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.
The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed to an accidental morphine overdose. They discuss how the case illustrates that small mistakes can combine to create major problems.