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Search results for "Medication Errors/Preventable Adverse Drug Events"
Legislation/Regulation > Organizational Policy/Guidelines
Bethesda, MD: American Society of Health-System Pharmacists; 2016.
Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards development project, this report describes how standardization can improve reliability and safety of intravenous therapy and provides guidance on safe concentrations for drugs.
Journal Article > Study
Sharif I, Tse J. Pediatrics. 2010;125:960-965.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.
Journal Article > Study
Garnerin P, Perneger T, Chopard P, et al. Anaesthesia. 2007;62:1090-1094.
Efforts toward standardization remain an important mechanism to address safety issues, such as with wristband use and drug labeling and package design. This study assessed the impact of different drug label information on injectable drug selection errors. Investigators provided three formats for conveying the concentration, quantity, and volume of a drug and evaluated the frequency of errors committed through a simulated exercise. They discovered significantly lower error rates with one of the formats in particular and call for regulatory bodies to implement standards on how such information should be displayed on injection drug labels.
Beyzarov E. Drug Topics / Health-System Edition. September 18, 2006.
This article discusses the contamination and sterility issues inherent in the process of compounding drugs.
Cases & Commentaries
- Web M&M
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.