- The average 200-bed hospital
administers over one million medication doses annually
- 10 – 20% of all doses are calculated at the point of care
- Miscalculations cause patient harm in 2.25 of every 1,000 doses given
- 41% of fatal medication errors are due to wrong doses
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Brick by brick, hospitals are building a medication error barrier with
technology and practices that guard against Preventable Adverse Drug
Events (PADEs).
Even with the immense
investment, patients remain at risk where gaps in the barrier allow
systemic errors to become harmful events.
One especially threatening gap occurs when high-risk IV injectible and
infusion medications are given “stat” without pharmacist preparation
and review. In these cases, nurses are required to calculate the
appropriate drug volume on the spot. On-the-spot calculations are also
required when unit dose medications are unavailable and in hospitals
without 24-hour pharmacy service.
Although infrequently documented, nurses know that every on-the-spot
dose calculation could result in dangerous wrong dose errors. No matter
how you add it up, mental math and emergency situations add up to
unnecessary risk for patients.
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