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June 7, 2004 12:01 AM

Broken: Drug bottles

Kevin Speicher sends an article from CBC (Canadian Broadcasting Corporation), Drug error kills 2 Alberta hospital patients. Excerpt:

Health officials in Calgary issued an emotional public apology Thursday to the relatives of two patients who died after receiving the wrong drugs during dialysis...Both compounds were purchased from the same company and had identically shaped bottles and similar packaging. ...The health region said it's taken steps to prevent a similar tragedy, such as marking potassium chloride with bright green labels and storing it in secure areas.


This is a well known error. In most US hospitals Potassium Chloride is never sent to general wards for admixture there; all mixing is done in a central supply or pharmacy area.

A really good book on systemic medical errors (of which this is a perfect example) is Internal Bleeding: The Truth Behind America's Terrifying Epicemic of Medical Mistakes

by Robert M., Md. Wachter, Kaveh G., Md. Shojania

ISBN: 1590710169

Posted by: Michael Moore at June 17, 2004 05:45 PM

Common error.

Posted by: c at January 16, 2005 09:14 PM

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