Nurse-administering errors occur for a number of reasons, including fatigue from working long hours, memory lapses, figure of speech packaging and sound-alike names of medications (Cowley, 1995).
A review of 10 incidents of patient death resulting from misadministration of potassium chloride showed that eight were the result of direct extract of concentrated potassium chloride according to the Sentinel Event Alert, (1998). In six of the eight cases, potassium chloride was mistaken for some other medication, primarily due to similarities in packaging and labeling. The most shop problem was mistaking potassium chloride for sodium chloride, he
Voelker, R. (1996, November 20). "Treat systems, not errors" experts say. JAMA. pp. 1537-1538.
Smith, J. (1995, September). Preventing medication errors. Nursing Homes. pp. 22-23.
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