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Unavailable patient information prior to dispensing or administering a drug (lab
values, allergies, etc.)
Unavailable drug information (written resources)
Miscommunication of drug orders (similar names, use of zeros, inappropriate
abbreviations, poor handwriting)
Problems with labeling, packaging
Drug standardization, storage (stocking multiple concentrations of the same drug,
look-a-like containers)
Drug device use and monitoring (lack of standardization in drug delivery devices,
unsafe equipment)
Environmental stress (distractions, noise during transcription or dispensing, too long
shifts)
Limited staff education (on problem prone drugs)
Limited patient education
High-alert medications are drugs that bear a heightened risk of causing significant
patient harm when they are used in error.
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