MEDICATION ERRORS: Fooling the robot

January 2005 
Volume 35  Number 1
Pages 14 - 15
  PDF Version Available!

© 2005 Lippincott Williams & Wilkins, Inc. Volume 35(1)             January 2005             pp 14-15 Fooling the robot [MEDICATION ERRORS: DRUG MIX-UP]


President of the Institute for Safe Medication Practices

The staff in a hospital pharmacy typically packaged unit doses of the calcium channel blocker nifedipine for use with robotic dispensing equipment. They used a different unit-dose packaging system for the lipid-lowering drug fenofibrate (Tricor), which wasn't used with the robotic system.

A nurse who was administering medications discovered a dose of fenofibrate in a unit-dose package labeled “nifedipine extended release 30 mg.” A review of the packaging logs and inventories for both drugs didn't reveal any errors, but the nurse said that the nifedipine package seemed to have a slight tear in it.

Further investigation ...

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