Look-alike packaging contributes to patient death

Canadian Pharmacists Journal

Volumn 139, Issue 1, 2006, Pages 57-58

  Greenall, Julie ^a   Wichman, Kristina ^a  

^a ISMP Canada   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

CHLORAL HYDRATE; POTASSIUM CHLORIDE;

APNEA; CANADA; DEATH; DROWSINESS; DRUG FATALITY; DRUG MANUFACTURE; DRUG PACKAGING; DRUG USE; HEALTH CARE DELIVERY; HUMAN; LETHARGY; MEDICATION ERROR; NURSING HOME; PHARMACIST; PHARMACY; RISK ASSESSMENT; RISK FACTOR; ROOT CAUSE ANALYSIS; SAFETY; SHORT SURVEY; UTILIZATION REVIEW;

EID: 33645029584     PISSN: 17151635     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Short Survey

References (6)

1. Human factors and substitution errors. ISMP Can Safe Bull 2003;3(5):1-2.
2. Concentrated potassium chloride: a recurring danger. ISMP Can Safe Bull 2004;4(3):1-2.
3. Morphine ampoule look-alike packaging alert. ISMP Can Safe Bull 2004; 4(11):1-2.
4. Report of near miss with succinylcholine warrants action. ISMP Can Safe Bull 2005;5(4):1-2.
5. ISMP's list of high alert medications. Huntingdon Valley (PA): Institute for Safe Medication Practices; 2005. Available: www.ismp.org/Tools/ highalertmedications.pdf. (accessed October 21, 2005).
6. System vulnerabilities across the spectrum of care: another mix-up between chloral hydrate and potassium chloride. ISMP Can Safe Bull 2005;5(7):1-2.