AUTHOR BIOGRAPHY
Myungsun Ro, PharmD, MS, DSRT, Patient Safety Authority
Myungsun (Sunny) Ro (mro@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority (PSA). Her responsibilities include analyzing and synthesizing data from various sources to identify opportunities to improve patient safety, as well as writing scientific articles for publication in PSA’s peer-reviewed journal, Patient Safety.
ABSTRACT
The Patient Safety Authority (PSA) recently received a report describing a fatal medication error that highlights persistent risks involving wrong drug events. In this event, a patient who was prescribed a medication typically used to treat high blood calcium levels inadvertently received a fatal dose of a neuromuscular blocking agent (NMB) instead.
Investigation into this event revealed a series of system vulnerabilities that contributed to it. The initial error occurred when the wrong medication, which was stocked next to the intended medication, was selected from the refrigerated dispensing area in the pharmacy. A wrong drug alert was generated during the dispensing process but was overridden. Subsequently, the pharmacist performing the final verification missed the error.
