MEDICATION ERRORS: Suspect the system

January 2005 
Volume 35  Number 1
Pages 14 - 14
  PDF Version Available!

© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(1)             January 2005             p 14 Suspect the system [MEDICATION ERRORS: ROOTING OUT ERRORS]


President of the Institute for Safe Medication Practices

A prescriber handwrote an order for the anticonvulsant carbamazepine, 400 mg, for an adult with a history of seizures. The pharmacist mistakenly retrieved the patient profile of a 4-year-old child with the same last name. Failing to recognize that the patient was a child and that the prescribed amount represented an overdose, he entered the medication into the patient record. When a pharmacy computer-generated medication administration record (MAR) was delivered to the unit that night, the nurse didn't notice anything wrong.

The next morning, a nurse didn't recognize that the dose was excessive or ask why the pharmacy had sent oral ...

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