Medication safety: Fatal prescription

27 Feb 2018 | Medication Safety

A junior doctor working in an unfamiliar hospital during a long and busy shift, is asked to prescribe morphine for a patient. The doctor selects the first of many options in a database list and prescribes a 200mg dose.  This is administered by a junior nurse, and the patient dies. 

The recently published article in the British Journal of Clinical Pharmacology highlights system issues contributing to medication errors. In any setting where professional competency and cognitive factors are an issue, system design and safety features are another. It raises a potential unintended consequence in digital system advancement.

The medication safety programme has a current workstream partnering with Health Information Standards Organisation looking into improving digital system standards for medicines management in New Zealand.

Read the full article here:

Last updated 27/02/2018