Annie Mercer

Bearing that qualification in mind, I recommend that consideration be given to the following measures as a means whereby errors of the kind in this case might be avoided, and where, in the event of an error being made, it might more readily be detected and its consequences avoided, or at least mitigated. First, in the case of acute emergency patients, medical staff should be encouraged to scrutinise drug kardexes on a daily basis even where there has been no change in the patient’s clinical condition. Second, in the case of drugs where dosage is determined by reference, inter alia, to the patient’s weight, consideration should be given to devising a form of drug kardex which would include a section setting out the calculation whereby the dosage has been arrived at.