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How Some Dosage Errors Occur

New Mexico patients may be interested to learn that some harmful errors in drug prescribing occur because of 10-fold dosage mistakes. For example, a trailing zero, such as 1.0 mg, might be misread as 10 mg. Similarly, the lack of a leading zero could lead to confusion between .5 mg and 5 mg.

One way this kind of error could be prevented is by not developing doses that differ by a factor of 10. Another possibility is in naming conventions. One company labeled its 12.5 mcg dose as Duragesic-12 to distinguish it from the 125 mcg dose.

One child was given 68 doses of Abilify that were ten times higher than they should have been, and it caused him to become withdrawn and depressed. Another prescription for doxepin 10 mg was recorded as doxepin 100 mg, and the error was not discovered for a month. The patient suffered from fatigue and drowsiness as a result. Belbuca is a pain reliever that was dispensed at 750 mcg to a patient when it should have been 75 mcg. It is not clear what the source of this error was, but the woman suffered from nausea, vomiting, dizziness, and an inability to sleep after taking five doses.

While in these cases it was possible for patients to recover from the mistakes, in other cases, a medication error could lead to a significant setback in a person’s treatment or could even be fatal. If the error is the result of medical malpractice, the medical professional responsible might be held financially responsible for the losses caused as a result. In determining whether medical malpractice has occurred, the court will consider whether the practitioner failed to exhibit the requisite standard of care.


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