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Poison Centre Research

An analysis of fatal iatrogenic therapeutic errors reported to United States poison centers

ORCID Icon, ORCID Icon &
Pages 53-60 | Received 02 Dec 2019, Accepted 01 May 2020, Published online: 28 May 2020

References

  • Kiekkas P, Karga M, Lemonidou C, et al. Medication errors in critically ill adults: a review of direct observation evidence. Am J Crit Care. 2011;20(1):36–44.
  • Institute of Medicine. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000. p. 312.
  • Berdot S, Gillaizeau F, Caruba T, et al. Drug administration errors in hospital inpatients: a systematic review. PLoS One. 2013;8(6):e68856.
  • Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299–309.
  • Beuhler MC, Dulaney AR. Further case details regarding IV N-Acetylcysteine overdoses. Clin Toxicol. 2011;49(9):878–878.
  • Heard K, Schaeffer TH. Massive acetylcysteine overdose associated with cerebral edema and seizures. Clin Toxicol. 2011;49(5):423–425.
  • American Association of Poison Control Centers (AAPCC). NPDS Coding Users’ Manual. Version 4.0. Arlington (VA): AAPCC; 2019. pp. 1–111.
  • Hodges NL, Spiller HA, Casavant MJ, et al. Non-health care facility medication errors resulting in serious medical outcomes. Clin Toxicol. 2018;56(1):43–50.
  • Takeshita H, Yasuda T, Nakajima T, et al. A death resulting from inadvertent intravenous infusion of enteral feed. Int J Legal Med. 2002;116(1):36–38.
  • Shah-Mohammadi A-R, Gaunt MJ. Oral medications inadvertently given via the intravenous route [Internet]. Harrisburg (PA): Pennsylvania Patient Safety Authority; Vol. 3, Pennsylvania Patient Safety Advisory, 2013 [cited 2019 December 1]. Available from: http://patientsafety.pa.gov/ADVISORIES/documents/201309_85.pdf
  • Saedder EA, Lisby M, Nielsen LP, et al. Detection of patients at high risk of medication errors: development and validation of an algorithm. Basic Clin Pharmacol Toxicol. 2016;118(2):143–149.
  • Christie LE, Picard J, Weinberg GL. Local anaesthetic systemic toxicity. BJA Education. 2015;15(3):136–142.
  • Food and Drug Administration. Drug Products Containing Colchicine for Injection; Enforcement Action Dates [Internet]. Silver Spring (MD): FDA; Federal Register 4160-01-S; Feb 8, 2008 [cited 2019 December 1]. Available from: https://www.govinfo.gov/content/pkg/FR-2008-02-08/pdf/08-564.pdf
  • Arbabian H, Lee HM, Graudins A. Elderly patients with suspected chronic digoxin toxicity: a comparison of clinical characteristics of patients receiving and not receiving digoxin-fab. Emerg Med Australas. 2018;30(2):242–248.
  • Carroll C, Hassanin A. Polypharmacy in the elderly-when good drugs lead to bad outcomes: a teachable moment. JAMA Intern Med. 2017;177(6):871–871.
  • Pea F. β-blockers and diltiazem combination-bear in mind the risk of heart block. JAMA Intern Med. 2017;177(10):1543–1544.
  • McLeod SE, Lum E, Mitchell C. Value of medication reconciliation in reducing medication errors on admission to hospital. J Pharma Pract Res. 2008;38(3):196–199.
  • Schochet SS, Lampert PW, Earle KM. Neuronal changes induced by intrathecal vincristine sulfate. J Neuropathol Exp Neurol. 1968;27(4):645–658.
  • Groudine SB, Cresanti-Daknis C, Lumb PD. Successful treatment of a massive intrathecal morphine overdose. Anesthesiology. 1995;82(1):292–295.
  • Shirley KW, Kothare S, Piatt JH, et al. Intrathecal baclofen overdose and withdrawal. Pediatr Emerg Care. 2006;22(4):258–261.
  • Kamboj A, Spiller HA, Casavant MJ, et al. Antidepressant and antipsychotic medication errors reported to United States poison control centers. Pharmacoepidem Drug Safe. 2018;64(14):S3–S10.
  • Kamboj AK, Spiller HA, Casavant MJ, et al. Non-health care facility cardiovascular medication errors in the United States. Ann Pharmacother. 2017;51(10):825–833.
  • Brophy TJ, Spiller HA, Casavant MJ, et al. Medication errors reported to U.S. Poison Control Centers, 2000–2012. Clin Toxicol. 2014;52(8):880–888.
  • Blanc PD, Kearney TE, Olson KR. Underreporting of fatal cases to a regional poison control center. West J Med. 1995;162(6):505–509.
  • Hoppe-Roberts JM, Lloyd LM, Chyka PA. Poisoning mortality in the United States: comparison of national mortality statistics and poison control center reports. Ann Emerg Med. 2000;35(5):440–448.
  • Leonard JB, Klein-Schwartz W. The others: characterizing “other” therapeutic errors reported to a poison center. Clin Toxicol. 2019;47:1–5.
  • Hayes BD, Klein-Schwartz W. Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults. Clin Toxicol. 2010;48(1):68–71.

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