April 2005, Volume 35 Number 4 , p 10 - 10
© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(4) April 2005 p 10 Small fix, big improvement [MEDICATION ERRORS: DIFFERENTIATING DOSAGES]
COHEN, MICHAEL R. RPH, MS, ScD
President of the Institute for Safe Medication Practices
A hospital stocked both 0.1 mg/ml and 1 mg/ml concentrations of hydromorphone to have it available for patient-controlled analgesia (PCA). To eliminate the risk of tenfold dosing errors, however, the hospital stopped stocking the higher concentration. Clinicians soon began complaining because they found that having only the 0.1 mg/ml concentration wasn't adequately meeting patients' needs.
The hospital restored the use of two concentrations. However, the pharmacy now provides concentrations of 0.2 mg/ml and 1 mg/ml to decrease the risk of confusing two concentrations that contain the numeral “1.” No hydromorphone ...