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"A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months." ..."Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms." Read what Brianna A. da Silva, MD* and Mahesh Krishnamurthy have to say, and learn about the Swiss Cheese Model of how errors occur in a system.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016741/ |