Potassium overdose using an oral solution: Potassium element expressed in grams as a packaging flaw contributing to medication error.
Défaut de conditionnement
Erreur médicamenteuse
Medication error
Oral solution
Packaging flaw
Potassium
Solution buvable
Journal
Annales pharmaceutiques francaises
ISSN: 0003-4509
Titre abrégé: Ann Pharm Fr
Pays: France
ID NLM: 2985176R
Informations de publication
Date de publication:
May 2021
May 2021
Historique:
received:
17
06
2020
revised:
09
10
2020
accepted:
13
10
2020
pubmed:
26
10
2020
medline:
26
10
2021
entrez:
25
10
2020
Statut:
ppublish
Résumé
Drug packaging contributes to the harm-benefit balance of a treatment. Poorly designed packaging can lead to drug misuse with serious consequences. We report a potassium double dose medication error concerning an oral solution. It was triggered by a packaging flaw related to the dosage indicated on the box, expressed for both potassium salt and elemental potassium. Standardizing the units used on packaging and for prescriptions, by using millimoles, could be a solution to avoid this type of medication error.
Identifiants
pubmed: 33098873
pii: S0003-4509(20)30124-3
doi: 10.1016/j.pharma.2020.10.008
pii:
doi:
Substances chimiques
Potassium
RWP5GA015D
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
286-290Informations de copyright
Copyright © 2020 Académie Nationale de Pharmacie. Published by Elsevier Masson SAS. All rights reserved.