Potassium overdose using an oral solution: Potassium element expressed in grams as a packaging flaw contributing to medication error.

Charpiat, B; Veremme, L; Duriez, B; Sigal, A

Charpiat, B; Veremme, L; Duriez, B; Sigal, A.

Afiliación

Charpiat B; Service pharmacie, hospices civils de Lyon, hôpital de la Croix-Rousse, 69004 Lyon, France. Electronic address: bruno.charpiat@chu-lyon.fr.
Veremme L; Service pharmacie, hospices civils de Lyon, hôpital de la Croix-Rousse, 69004 Lyon, France.
Duriez B; Service des urgences, hospices civils de Lyon, hôpital de la Croix-Rousse, 69004 Lyon, France.
Sigal A; Service des urgences, hospices civils de Lyon, hôpital de la Croix-Rousse, 69004 Lyon, France.

Ann Pharm Fr ; 79(3): 286-290, 2021 May.

Article en En | MEDLINE | ID: mdl-33098873

RESUMEN

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.

Asunto(s)

Sobredosis de Droga; Embalaje de Medicamentos; Humanos; Errores de Medicación; Potasio

Palabras clave

Défaut de conditionnement; Erreur médicamenteuse; Medication error; Oral solution; Packaging flaw; Potassium; Solution buvable

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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Embalaje de Medicamentos / Sobredosis de Droga Límite: Humans Idioma: En Revista: Ann Pharm Fr Año: 2021 Tipo del documento: Article Pais de publicación: Francia

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