Can You Spot the Drug Safety Hazard?
A potential medication error is lurking in each of these 6 photos.
I
t's no secret that poor documentation, dangerous abbreviations
and unlabeled syringes can lead to harmful medication errors or
adverse drug events. What's surprising is how often they occur in
surgery. See if your nursing and anesthesia providers can spot the
medication error in each of these 6 real-life photos. Let's start with a
common drug charting infraction: trailing zeros and naked decimal
points.
• No trailing zeros.
Is this 1 mg or 10 mg
of midazolam? One
of the most danger-
ous and frequent
error-prone abbrevi-
ations is the trailing
zero after a decimal
point — 1.0 mg in
this example. The
correct entry would
simply be "1 mg." If
you don't see the decimal point, 1.0 could be administered as 1 mg or
10 mg — admittedly a high dose, but a ten-fold dosing option is feasi-
ble with midazolam. Regardless, never add a trailing zero.
Similarly, shield your eyes from naked decimal points (one without
a leading zero). Never write a dose as .5 mg, for example. For clarity,
always apply a lead zero before a decimal point when the dose is less
than a whole unit — 0.5 mg in this example. If you don't see the deci-
mal point, you can easily interpret .5 mg as 5 mg.
2 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J U L Y 2 0 1 8
Safety
Sheldon S. Sones, RPh, FASCP
