title: An unusual 'near miss'...but it's nothing new.
authors.forename: M
authors.initials: M
authors.lastname: Kalupahana
mesh_terms: D019342:Acetic Acid; D002021:Buffers; D002951:Citrates; D004348:Drug Labeling; D004349:Drug Packaging; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control; D000077559:Sodium Citrate
chemical_list: D002021:Buffers; D002951:Citrates; D000077559:Sodium Citrate; D019342:Acetic Acid