Founder and President, Institute for Safe Medication Practices Horsham, Pa.

You likely heard about this incident in the news earlier this year: A woman died after receiving the paralyzing agent vecuronium instead of the sedative midazolam (Versed, discontinued brand) when the wrong medication was retrieved from an automated dispensing cabinet (ADC) (see sidebar).
Starting in January 2019, the Institute for Safe Medication Practices (ISMP) published a series of articles