MEDICATION ERROR: Better communication: Talk the talk
Michael R. Cohen RPH, MS, ScD

June 2006 
Volume 36  Number 6
Pages 15 - 15
  PDF Version Available!


Sorted by brand name, the antiarrhythmic Brevibloc (esmolol) and the anesthetic Brevital (methohexital) wound up next to each other on an automated dispensing cabinet screen in a hospital procedural area. A nurse accidentally removed Brevibloc instead of Brevital and eventually placed the wrong medication at the patient's bedside. Fortunately, another nurse and the physician caught the error during the “time-out” period immediately before the procedure.

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