One Tablet or One Bottle? Avoiding Mix-Ups between Sterile Water and Sodium Chloride Bags a Chain is Only as Strong as its Weakest Link

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs.

Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR).

Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.

Errors, close calls, or hazardous conditions may be reported through the ISMP (www.ismp.org) or United States Pharmacopeia (USP) (www.usp.org) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.