MEDICATION ERRORS: Five flaws in drug delivery
Michael R. Cohen RPH, MS, ScD

September 2007 
Volume 37  Number 9
Pages 10 - 10
  PDF Version Available!


Cohen, Michael R. RPH, MS, ScD

President of the Institute for Safe Medication Practices The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at or the United States Pharmacopeia (USP) at . You can also call ISMP at 1-800-FAIL SAFE or send an e-mail message to Michael R. Cohen is a member of the Nursing2007 editorial advisory board.

At least five staff members overlooked a prescribing error, and safeguards such as warning labels and double checks didn't prevent the error from reaching the patient.

1. A medical resident using computerized prescriber order entry (CPOE) at a remote site intended to prescribe an infusion of the neuromuscular blocking agent (NBA) vecuronium (Norcuron) for a patient on mechanical ventilation ...

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