The alert, issued Sept. 12, concerns a VA medical center reporting that the wrong concentration of dialysis solution was used on a hemodialysis patient.
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A contributing factor was that the containers of the solution that was intended for the patient and the solution that was inadvertently used look very similar.
To view the patient safety alert, which includes images of the containers, click here (pdf).
Related Articles on Look-Alike Challenges:
8 Ways for Surgery Centers to Reduce Look-Alike/Sound-Alike Drug Errors
Ambulatory Surgery Medication Errors Spotlighted in New Pennsylvania Report
20 Questions Surgery Centers Should Ask to Ensure an Effective Safe Medication Management Program
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