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Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
PA-PSRS Patient Saf Advis. June 2008;5:53-56.
This article reports on cases of improper IV administration of sterile water, a high-alert substance, for the treatment of hypernatremia and provides risk reduction strategies for this potentially fatal error.