ISMP Safety Brief: Prevent Additional Patient Harm and Deaths From Accidental Daily Methotrexate Dosing
National Association of Boards of Pharmacy
MARCH 22, 2024
The community pharmacy dispensed a three-month quantity of medication but provided instructions on the label to take 15 mg (six 2.5 The error was discovered three weeks later during patient counseling with a pharmacist when the patient requested a refill. mg tablets) once daily.
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