title: Narrowing the margin of error.
abstract: The patient had been feeling remarkably well 24 hours post-operatively. She remained on intravenous feeding and medication, although she was ambulatory. That afternoon, she realized something was wrong. She was experiencing an overall, generalized weakness, difficulty breathing, and wheezing. In response to her breathing problems, she had used her Serevent (once in the morning) and albuterol inhalers (every four hours), but had achieved no relief. It wasn't until 10:00 p.m. that evening, when she questioned whether or not she had received her dose of prednisone that day which she had been on prior to surgery, that the problem was identified. Despite a detailed history of medication changes, which had been recorded and reported to the anesthesia department prior to surgery, the prednisone dose had been missed.
authors.forename: D H
authors.initials: DH
authors.lastname: Smith
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control