Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet.
editorial · Level V
Where this comes from
- Record sourced from PubMed, PMID 36333160.
- Also identified by DOI 10.1016/j.bja.2022.09.017.
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Abstract
An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.
Medical subject headings
- Medication Systems, Hospital
- Medication Errors