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ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.
 

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.
 
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Resource Type:  Journal Article > Commentary

Setting of Care:  Hospitals

Target Audience:  Health Care Providers

   Health Care Executives and Administrators > Quality and Safety Professionals

Clinical Area:  Medicine > Internal Medicine > Allergy & Immunology

   Medicine > Internal Medicine > Cardiology

   Medicine > Pediatrics > Pediatric Allergy & Immunology

   Medicine > Pediatrics > Pediatric Cardiology

   Pharmacy > Hospital Pharmacy

Safety Target:  Medication Safety > Medication Errors/Preventable Adverse Drug Events

   Medication Safety > Specific to High-Risk Drugs > Look-Alike, Sound-Alike Drugs

Error Types:  Active Errors

Approach to Improving Safety:  Communication Improvement > Communication between Providers

   Education and Training

Origin/Sponsor:  North America > United States of America
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