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Drug shortages can lead to dosage errors

A drug shortage that led to dosage errors has been used as an example to help hospitals in South Carolina and other states determine how these mistakes occurred and to help prevent these types of errors in the future. At the end of 2010, the drug potassium acetate in the dosage of 2 mEq/mL was in short supply. To ensure that this drug was still available to patients, MedStar Health acquired 4 mEq/mL dosages of the drug. However, the dosage difference was not entered into hospital computers, and patients taking the drug received the wrong dosage.

Fortunately, no one was harmed due to this error, and the company made the mistake known to other health care systems and providers. Once their investigation was completed, MedStar Health also made the findings of the investigation available.

Those who investigated the issue discovered that a high level of trust among staff led to only cursory inspections of drug dosages. This trust led to an incredibly low expectation of errors, so people were not as careful as they could have been. Additionally, the investigation found that it was not uncommon for buyers to fail to notify the pharmacy supervisor when a different drug was purchased.

While this case in particular did not lead to injury to patients, receiving the wrong drug or an incorrect dosage can lead to major health issues for people. Concentrations that are too high can greatly increase the risk of side effects and even overdosing, and medications that are not strong enough will not properly treat medical issues. A lawyer may be able to help someone who has been harmed by an incorrect dosage understand their legal options for recourse.

Source: Pain Medicine News, "A Dangerous Interplay: Rx Shortages and Med Errors", May 27, 2013

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