September 2007, Volume 37 Number 9 , p 10 - 10
Cohen, Michael R. RPH, MS, ScD
President of the Institute for Safe Medication Practices The reports described in Medication Errors were received through the USP-ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at http://www.ismp.org or the United States Pharmacopeia (USP) at http://www.usp.org . You can also call ISMP at 1-800-FAIL SAFE or send an e-mail message to firstname.lastname@example.org. Michael R. Cohen is a member of the Nursing2007 editorial advisory board.
At least five staff members overlooked a prescribing error, and safeguards such as warning labels and double checks didn't prevent the error from reaching the patient.
1. A medical resident using computerized prescriber order entry (CPOE) at a remote site intended to prescribe an infusion of the neuromuscular blocking agent (NBA) vecuronium (Norcuron) for a patient on mechanical ventilation ...