Poison center utilization in nosocomial toxicologic exposures: a prospective study

Accidental toxicologic exposures that occur within health care facilities (HCF's) have the potential to increase morbidity and mortality, as well as enhance medicolegal liability. By contacting the poison center immediately on recognition of these events, health care providers may ultimately lessen eventual toxic effects through appropriate intervention. Exposures of this nature reported to the poison center over a twelve month period were collected and tabulated for specific occurrences. Six categories of therapeutic misadventure were delineated: Right patient/wrong medication (18%); Right patient, right medication/wrong dose or route (16%); Lack of patient education (2%); Proximity of potentially harmful substances to confused persons (54%); and Incorrect equipment management (4%). This study seeks to increase awareness of poison center ability to assist in management of the "therapeutic misadventure."