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Updated: Aug 23, 2025

A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings
Published on: November 9, 2016
Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet
T Andrew Bowdle1, Srdjan Jelacic1, Craig S Webster2
1Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
Abstract:
An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.
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