Cases & Commentaries
A hospitalized pediatric burn patient underwent dressing changes and burn inspection every third day. On those days she received oxycodone for pain, which allowed her to tolerate the painful procedures and to rest. After a dressing change one day, the mother noticed the child's breathing was shallow. That day the patient had received three doses of oxycodone, but because the automated dispensing machine had been stocked incorrectly with a higher concentration of oxycodone solution stored in the location normally reserved for the lower concention, she received nearly five times the dose ordered. In the accompanying commentary, Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc, of the Institute for Safe Medication Practices Canada, describe ways to enhance safety of automated dispensing cabinet use in hospitals, including barcode-assisted medication administration and providing standard or ready-to-administer doses.