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Editorial
. 2023 Jan;130(1):14-16.
doi: 10.1016/j.bja.2022.09.017. Epub 2022 Nov 1.

Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet

T Andrew Bowdle  1 , Srdjan Jelacic  2 , Craig S Webster  3 , Alan F Merry  3
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Free article
Editorial

Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet

T Andrew Bowdle et al. Br J Anaesth. 2023 Jan.
Free article

Abstract

An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.

Keywords: drug dispensing; medical informatics; medication error; neuromuscular blocking drug; patient safety.

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