. "Part I Understanding the Causes and Costs of Medication Errors ." Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press, 2007.
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Preventing Medication Errors
Key Element
Latent Failures
Active Failures
warn that drug can be administered IM only.
Conflicting information about IV use of milky-white substances.
Lack of FDA requirement for “black box” or other vivid warning regarding IV administration of penicillin G benzathine in drug monographs.
Competency
Hospital had an unclear definition of prescriptive authority for nonphysicians.
Nurse practitioner assumed authority to change route of administration based on national protocol and current practice in hospital.
Labeling, Packing, and Nomenclature
Manufacturer’s warning for “IM use only” not prominently placed on syringe: syringe had to be rotated 180 degrees away from drug name to view the warning; plunger obscured the view after syringe prepared; “1,200,000” used instead of “1.2 million” units (errors occur when comma is misread).
Warning on syringe for “IM use only” not seen.
Ten-fold overdose not recognized.
Penicillin G benzathine administered intravenously.
SOURCE: Smetzer and Cohen, 1998.
REFERENCES
Reason, J. 1990. The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London, Series B 327, 475–484.
Smetzer JL, Cohen MR. 1998. Lessons from the Denver medication error/criminal negligence case: Look beyond blaming individuals. Hospital Pharmacy 33(6):640–657.
