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J Perianesth Nurs. 2007 Dec;22(6):413-9.

Medication errors in the PACU.

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Center for the Advancement of Patient Safety, U.S. Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD 20852, USA.


A collaborative research group examined seven years of PACU medication errors from the MEDMARX database. Descriptive statistics showed a comparison of medication errors in all ages from pediatric to adult to geriatric groups. Nine categories of medication errors were noted and a total of 3,023 errors were attributed to errors in prescribing, transcribing, dispensing, administering, and monitoring. Harmful errors were present in 5.8% of the sample, which included two patient deaths. Results indicated that errors can occur in any age group. Organizations and institutions should be aware of these occurrences to ensure vigilance at all times and to focus efforts toward avoiding or decreasing such errors. Patient safety and error prevention recommendations are provided.

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