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American Journal of Health-System Pharmacy

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We read with disbelief about a newly graduated pharmacist dispensing 30 times the amount of injectable sodium bicarbonate intended, an error that led to a patient’s death.1 As clinicians, we wondered what clinical scenario might mandate the large amount of sodium bicarbonate dispensed—the answer was none. So why did the pharmacist dispense it? The answer is all too clear: With rare exceptions, institutional pharmacists nationwide are largely focused on dispensing. Postgraduate clinical training in the basic aspects of pharmacotherapy is scarce and not viewed as essential. Inadequate pharmacist training and a staffing shortage were suggested as contributing to the death of a six-day-old infant who received 10 times the prescribed dose of i.v. potassium chloride at a university hospital.2 These two sobering misadventures hint at a link between pharmacists’ clinical training and patient safety.


This is a post-print version of an article originally published in American Journal of Health-System Pharmacy, 2010, Volume 67, Issue 6.

The version of record is available through: the American Society of Health-System Pharmacists.