MEDICATION ERRORS: Potpourri of problems
MICHAEL R. COHEN RPH, MS, ScD, President of the Institute for

November 2004 
Volume 34  Number 11
Pages 20 - 20
  PDF Version Available!


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    The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires you to use at least two patient identifiers (other than room number) when you take blood or administer medications or blood products. The following scenarios show that “wrong patient” errors can originate in various phases of the medication process:

    Mixed-up names . A pharmacist tried to access a pharmacy computer profile for a male patient named Franklin Hope (fictitious name). When he couldn't locate the profile using the patient's ID number, he entered “Franklin Hope” and patient information appeared on screen. He then noticed that the patient was identified as female and realized that he was viewing the profile for Hope Franklin!

    Mixed-up monitoring . A telemetry monitor showed that a patient had atrial fibrillation and flutter with a heart rate of 140. The physician ordered the calcium channel ...

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