Article authored by ISMP staff member Matthew Grissinger and FDA/ISMP Fellow Jessica Trinh discusses the contributing factors involved in the case of a 17-year-old girl who died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentanyl. They emphasize the need for a multifaceted approach to enhancing medication safety that encompasses risk identification, targeted interventions, and collaboration across healthcare settings.
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