Abstract
BACKGROUND: Medication errors are a frequent problem in the accident and emergency (A&E) department.
CASE DESCRIPTION: A 17-year-old boy was referred to our A&E department with an anaphylactic reaction to peanuts. Because of various shortcomings in the care process in A&E, adrenaline was administered intravenously instead of intramuscularly, resulting in a broad complex tachycardia. We analysed these shortcomings using the 'Prevention and recovery information system for monitoring and analysis' (PRISMA) method.
CONCLUSION: Medication errors are usually a result of shortcomings in non-technical skills, such as communication and situational awareness. Training these skills by applying the concept 'Crew resource management' may reduce medication errors and improve patient safety.
| Translated title of the contribution | It is all about the form - adrenaline in anaphylaxis: intravenous or intramuscular administration? |
|---|---|
| Original language | Dutch |
| Article number | D1089 |
| Number of pages | 5 |
| Journal | Nederlands Tijdschrift voor Geneeskunde |
| Volume | 161 |
| Issue number | 26 |
| Publication status | Published - 2017 |