ISMP Medication Error Report Analysis - Electronic Prescribing Vulnerabilities: Height and Weight Mix-Up Leads to Dosing Error; Null Sign Misread; Look-Alike Vials.

The article focuses on the Institute for Safe Medication Practices' (ISMP) reported medication errors that occurred in health care facilities. It states that a reported case to ISMP Canada shows that a physician interchanged the patient's height and weight into the electronic chemotherapy prescribing system, which led to dosing error. It adds a report on misinterpretation of null sign as number four by two nurses that caused a patient's cardiac arrest due to basal infusion of morphine 4mg/hour.