Is it time to eliminate reverse numbering systems for narcotic counts?
ISMP has received several error reports involving administration of the wrong dose of an oral opioid due to reverse numbering systems on oral opioid unit dose blister packages. Learn how reverse numbering systems contributed to these errors and what some drug manufacturers are doing to remedy the problem. • Safety Brief: Drug name mix-up. Two patients received levetiracetam (KEPPRA) instead of levocarnitine (CARNITOR). Find out what strategies your organization can implement in order reduce the risk of mix-up between these two medications. • Safety Brief: Wrong insulin concentration. A patient received an insulin infusion that was five times the intended dose. Read more about this event, including the contributing factors that lead to the error, and ISMP’s recommendations for how other healthcare facilities can minimize the risk of a similar error within their own organization. • Safety Brief: Ambiguous bisacodyl directions. A patient misunderstood the directions for use on an over-the
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