| Origins of and solutions for neonatal medication-dispensing errors. | |
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MedLine Citation:
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PMID: 20044369 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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PURPOSE: Five cases of sound-alike, look-alike, neonatal medication-dispensing errors and their resolution are reviewed. SUMMARY: In 2008, there were five cases in which look-alike or sound-alike neonatal medication-dispensing errors occurred at our institution. A mix-up between neonatal and adult or pediatric products occurred in four of the five cases. Three of the five errors resulted in near misses with the potential to cause harm. The other two errors reached the patients but did not cause harm. The medication mix-ups involved adult and neonatal phytonadione injectable emulsion, sodium citrate injection and vancomycin-heparin combination injection, adult tetanus-diphtheria-acellular pertussis and infant diphtheria-tetanus-acellular pertussis (DTaP) vaccines, Haemophilus B and DTaP vaccines, and cisatracurium and vecuronium. Each error exposed weaknesses in the system of neonatal medication storage, labeling, delivery, knowledge, and administration documentation at our institution. Resolution of system problems was made possible by a collaborative approach and involved reorganizing shelving used to store neonatal medications; using a differently colored labeling scheme for products whose syringes were nearly identical; implementing changes to the infant vaccine ordering, storage, dispensing, and documentation systems; and instituting centralized and decentralized pharmacist review of pharmacy technician automated dispensing cabinet-filling activities. CONCLUSION: An institution providing services to both neonatal and adult patients experienced five cases of medication-dispensing errors with look-alike or sound-alike medications. Multidisciplinary collaboration within the system helped the pharmacy identify, resolve, and prevent errors related to medication storage, labeling, delivery, knowledge, and administration documentation. |
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Authors:
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Jason B Sauberan; Linda M Dean; Jessica Fiedelak; Julie A Abraham |
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Publication Detail:
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Type: Case Reports; Journal Article |
Journal Detail:
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Title: American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists Volume: 67 ISSN: 1535-2900 ISO Abbreviation: Am J Health Syst Pharm Publication Date: 2010 Jan |
Date Detail:
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Created Date: 2010-01-01 Completed Date: 2010-03-05 Revised Date: 2013-04-04 |
Medline Journal Info:
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Nlm Unique ID: 9503023 Medline TA: Am J Health Syst Pharm Country: United States |
Other Details:
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Languages: eng Pagination: 49-57 Citation Subset: IM |
Affiliation:
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Department of Pharmacy, University of California San Diego Medical Center, 200 West Arbor Drive, MC8765, San Diego, CA 92103, USA. jsauberan@ucsd.edu |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Citrates
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administration & dosage Diphtheria-Tetanus-acellular Pertussis Vaccines / administration & dosage Haemophilus Vaccines / administration & dosage Heparin / administration & dosage Humans Intensive Care Units, Neonatal / organization & administration* Medication Errors* Medication Systems, Hospital / organization & administration* Safety Management / organization & administration* Vancomycin / administration & dosage Vitamin K 1 / administration & dosage |
| Chemical | |
Reg. No./Substance:
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0/Citrates; 0/Diphtheria-Tetanus-acellular Pertussis Vaccines; 0/Haemophilus Vaccines; 1404-90-6/Vancomycin; 1Q73Q2JULR/sodium citrate; 84-80-0/Vitamin K 1; 9005-49-6/Heparin |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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