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Dangerous Dapsone.
Bookwalter T. AHRQ WebM&M [serial online]. June 2004.
 
A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly sevenfold overdose of dapsone.
 
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Resource Type:  Journal Article > Commentary

Setting of Care:  Ambulatory Care > Outpatient Pharmacy

Target Audience:  Health Care Providers

   Non-Health Care Professionals

Clinical Area:  Medicine > Internal Medicine > Medical Oncology

   Medicine > Hospital Medicine

   Pharmacy > Hospital Pharmacy

   Pharmacy > Community Pharmacy

Safety Target:  Medication Safety > Side Effects/Adverse Drug Reactions

   Medication Safety > Medication Errors/Preventable Adverse Drug Events > Ordering/Prescribing Errors

   Medication Safety > Medication Errors/Preventable Adverse Drug Events > Transcription Errors

   Medication Safety > Medication Errors/Preventable Adverse Drug Events > Dispensing Errors

Error Types:  Active Errors > Noncognitive Errors ("Slips & Lapses")

   Active Errors > Cognitive Errors ("Mistakes")

Approach to Improving Safety:  Communication Improvement > Communication between Providers

   Teamwork > Teamwork Training

   Specialization of Care > Clinical Pharmacist Involvement

   Technologic Approaches > Clinical Information Systems > Computerized Provider Order Entry (CPOE)

   Education and Training > Teamwork Training

Origin/Sponsor:  North America > United States of America > United States Federal Government > Department of Health and Human Services (HHS) > Agency for Healthcare Research and Quality (AHRQ)
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