How a Few Letters Can Spell Trouble

Many hospital medication cabinets can be searched by inputting only a few letters. Since 2017, there have been at least eight reports of hospital staff accidentally withdrawing and then administering or nearly administering the wrong drug for this reason. Because hospitals are not required to report most drug mix-ups, this is likely a small sampling of a much larger total.

*Unknown is whether the hospital staffer typed one or two letters.
Source: Institute for Safe Medication Practices error reports
KHN
Lydia Zuraw and Brett Kelman/KHN
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