MEDICATION ERRORS: Only as safe as facility policy

December 2005 
Volume 35  Number 12
Pages 10 - 10
  PDF Version Available!


A nurse who received an order for the antigout drug “colchicine 1.0 mg I.V. now” overlooked the decimal. Believing that the patient was to receive 10 mg, she retrieved ten 1 mg ampuls from an automated dispensing cabinet (ADC) that wasn't linked to the pharmacy computer.

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