South Dakota: A Sioux Falls Pharmacy Called the Prescriber Before a Harmful Dose Went Home
The story
Look-alike names and wrong doses happen in every state, including South Dakota.
ISMP cases show the near-miss that never becomes a funeral because someone asked a question.
What happened next
The patient drove away unaware, which is the best ending.
A lesson you can use this week
Ask what a new medicine is for and what would be an emergency.
Sources
Institute for Safe Medication Practices; South Dakota Pharmacists Association safety reminders.
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