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Preventing Drug Errors

Doctor admits drug blunder killing

This case has hit the headlines again - the accidental spinal injection of toxic drug vincristine rather than injecting cytosine, which led to the death of a patient in 2000. The two drugs were in almost identical syringes and were kept together in the same ward fridge.

The case has led to radical changes in the way that cytotoxic drugs are labelled, distributed and administered; amongst other changes, the drugs are now more distinctly labelled and not both made available at the same time.

The Committee on Safety of Medicines set up an expert working group to examine the role of medicines packaging and labelling in medication errors, its report is available here as a 96Kb PDF file.

Posted by Brian 22.9.03 [ page link ]


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