Medication Error Case Report
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Real Life Case Study Involving Medication Error
2015PMC4357082 Patient Saf Surg. 2015; 9: 12. Published online 2015 Mar 13. doi: 10.1186/s13037-014-0047-0PMCID:
Medication Error Scenarios
PMC4357082Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe systemJoerg Schnoor, Christina Rogalski, Roberto Frontini, Nils
Cases Of Medication Errors By Nurses
Engelmann, and Christoph-Eckhardt HeydeDepartment of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Office of Quality and Risk Management, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Department of Anesthesiology, King’s College Hospital Clinics Abu Dhabi LLC, Abu Dhabi, UAE Shining Towers, a case of medication error conversion factors in clinical calculations answers Mubarak bin Mohammed St, Khalidiyah, PO Box 129923, Abu Dhabi, UAE Pharmacy, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Department of Orthopedics, Traumatolgy and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103 Leipzig, Germany Joerg Schnoor, Email: ed.gizpiel-inu.nizidem@roonhcS.greoJ.Contributor Information.Corresponding author.Author information ► Article notes ► Copyright and License information ►Received 2014 Jul 23; Accepted 2014 Dec 9.Copyright © Schnoor et al.; licensee BioMed Central. 2015This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.AbstractBackgroundThe acronym LASA (look-alike sound-alike) denotes the problem of confusing similar- looking and/or sounding drugs accidentally. The most common causes of
in the Operating Room Hospital Coalition Group Endorses APSF Recommendations for PCA Monitoring
Letters to the Editor: Accidental Intrathecal Injection of Tranexamic Acid in a case of medication error by brahmadeo dewprashad answers Cesarean Section: A Fatal Medication Error Non-Opiate Analgesics & CPAP May Prevent medical error disclosure case study Postoperative Respiratory Depression Chlorhexidine-Alcohol Preparation Solution Contributes to Risk of Combustion Growing Pains: Unavoidable Collateral Damage or Time nursing medication error stories for a Warning? Gas Cylinder Colors ARE NOT an FDA Standard! Is Hydromorphone PCA Safer Than Morphine PCA? Syringe Labeling Made Simple Distractions in the Operating Room: Should the https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4357082/ Use of Personal Computers Be Banned during the Administration of Anesthesia? Letter to the Editor: Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section: A Fatal Medication Error by Firouzeh Veisi, MD; Babak Salimi, MD; Gholamreza Mohseni, MD; Parisa Golfam, MD; and Azam Kolyaei, BS To the Editor: Medication errors from look-alike ampoules continue to cause serious patient harm resulting http://www.apsf.org/newsletters/html/2010/spring/02_inject.htm from lack of systematic medication safety practices. We report a case of a fatal medication error for an emergency cesarean section for term twin delivery. Case Description: A 21-year-old woman with a 37-wk twin pregnancy came to the hospital emergency department due to painless vaginal bleeding, which started 6 hours prior to arrival. The patient's initial vital signs were: BP=100/70, T=37, HR=94/min, RR=18/min. Fetal heart rates were 140/min and 116/min. Emergency ultrasound revealed decreased amniotic fluid in Twin A and an incomplete placenta previa. The patient’s serum hemoglobin was 10 mg/dl. The patient was scheduled for a cesarean section due to vaginal bleeding and placenta previa. The anesthesiologist decided to administer spinal anesthesia and asked his technician to give him 1.5% bupivacaine. The technician took out an ampoule from a box, opened it, and gave it to the anesthesiologist. The anesthesiologist injected the drug after confirming free flow of cerebrospinal fluid. After injection, the patient was placed in the supine position for prepping and draping. Approximately 3 minutes after injection of the drug the patient begaBlog Submit Manuscript Menu About Contact Sustainability Press Releases Testimonials Blog Favored Author Program Permissions Pre-Submission Login open access to scientific and medical research Advanced search HomeBrowse JournalsWhy Dove?Editors-in-ChiefAuthor GuidelinesPeer Review https://www.dovepress.com/look-alike-sound-alike-medication-errors-a-novel-case-concerning-a-slo-peer-reviewed-article-IMCRJ GuidelinesOpen Outlook Average Article Statistics 18 Days * from submission to first https://primeinc.org/casestudies/pharmacist/study/812/Medication_Error:_Right_Drug,_Wrong_Route editorial decision. 32 Days * from editorial acceptance to publication. *Business days (Mon-Fri) 28257 Papers Published Submit Manuscript Journal Email Alerts Signup for Alerts About Dove Press Open access peer-reviewed scientific and medical journals. Learn more Open Access Dove Medical Press is a member of the OAI. Learn more Reprints medication error Bulk reprints for the pharmaceutical industry.
Learn more Favored Authors We offer real benefits to our authors, including fast-track processing of papers. Learn more Social Media Back to Browse Journals » International Medical Case Reports Journal » Volume 8 Case report Look-alike, sound-alike medication errors: a novel case concerning a Slow-Na, Slow-K prescribing errorAbstractFulltextMetricsGet Permission Authors Naunton M, Gardiner of medication error HR, Kyle G Received 3 December 2014 Accepted for publication 15 January 2015 Published 16 February 2015 Volume 2015:8 Pages 51—53 DOI https://dx.doi.org/10.2147/IMCRJ.S78637 Checked for plagiarism Yes Review by Single-blind Peer reviewer comments 3 Editor who approved publication: Prof. Dr. Ronald Prineas Mark Naunton, Hayley R Gardiner, Greg Kyle Discipline of Pharmacy, University of Canberra, Bruce, Australian Capital Territory, Australia Abstract: A 59-year-old man was mistakenly prescribed Slow-Na instead of Slow-K due to incorrect selection from a drop-down list in the prescribing software. This error was identified by a pharmacist during a home medicine review (HMR) before the patient began taking the supplement. The reported error emphasizes the need for vigilance due to the emergence of novel look-alike, sound-alike (LASA) drug pairings. This case highlights the important role of pharmacists in medication safety. Keywords: LASA, error, sodium, potassium This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are perAbout PRIME Case Studies Index Physician Case Studies Pharmacist Case Studies PA and NP Case Studies Case Manager Case Studies Employer Case Studies Random CME/CE Activity Addressing the Maze of Domestic Violence in Child Abuse, Elder Abuse, and Intimate Partner Aggression $25.00 2.0-Hour Monograph CME Intended Audience: Physicians, nurse practitioners, physician assistants, dentists, pharmacists, psychologists, and nurses Recent Headlines Comparative Benefits and Risks of RAAS Therapies for Essential Hypertension Posted on: 7/01/13 Acetaminophen-Induced Hepatotoxicity Posted on: 6/01/13 Managing Juvenile Idiopathic Arthritis (JIA) with DMARDs Posted on: 4/01/13 New Therapies for Partial-Onset Epileptic Seizures Posted on: 3/01/13 The Role of the Pharmacist in Managing Patients with Rheumatoid Arthritis Posted on: 2/01/13 Deterring Prescription Medication Abuse and Diversion: The Pharmacist's Responsibilities and Roles Posted on: 1/02/13 Tailoring Patient-Specific Treatment Approaches in Type 2 Diabetes Posted on: 12/01/12 Newer Treatment Options for Metastatic Castration-Resistant Prostate Cancer Posted on: 11/01/12 Managing Patient with Rheumatoid Arthritis: The Role of the Pharmacist Posted on: 10/01/12 The Role of the Pharmacist in Improving Outcomes in the Schizophrenic Patient: Balancing Pharmacological, Metabolic, Safety, and Adherence Concerns Posted on: 8/01/12 Is Natalizumab an Appropriate Treatment Option For This MS Patient? Posted on: 7/01/12 Management Strategies for Patients with Established Rheumatoid Arthritis Posted on: 6/01/12 Solifenacin for Overactive Bladder Posted on: 5/01/12 Management of Osteoarthritis Posted on: 4/01/12 Managing Juvenile Idiopathic Arthritis (JIA) with DMARDs Posted on: 3/01/12 Adherence to Oral Antidiabetic Medication and Glycemic Control Posted on: 2/01/12 Medication Error: Right Drug, Wrong Route Posted on: 1/01/12 Challenges in the Pharmacologic Management of Schizophrenia Posted on: 11/01/11 State of the Science in Metastatic Castration-Resistant Prostate Cancer (CRPC) Poste