title: [Drug mix-ups].
abstract: We investigated drug mix-ups at a Danish hospital. We found 115 drug mix-ups among 1,554 medication errors (7%). The majority were packing mix-ups with insulin, infusion fluids and prepared syringes. The most frequent cause of name confusions was illegible handwriting. Packing mix-up occurring during routine dispensing may be prevented with bar-coding, and package mix-ups occurring in acute situations may be prevented through better package design focusing on reducing the risk of mix-ups.
authors.affiliation: Administrationen, Hvidovre Hospital, DK-2650 Hvidovre.
authors.forename: Rie Harboe
authors.initials: RH
authors.lastname: Nielsen
authors.forename: Annemarie
authors.initials: A
authors.lastname: Hellebek
mesh_terms: D004348:Drug Labeling; D004349:Drug Packaging; D011307:Drug Prescriptions / Q000592:standards; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D012307:Risk Factors