Objective: To probe into the countermeasures and preventive measures of drug error through the full description of a case of medication error induced by infusion of high concentration of potassium chloride. Methods: A investigation into the cause

the process

the disposal

the case-reviewing and the post-processing of this medical accident was performed to provide effective treatment and prevention of medication errors. Results: The adverse accident was classified as class F to H of the third level of medication errors. The treatment of the adverse event was in time

which minimized the damage induced by medication errors. Conclusion: By improving and implementing relevant systems

strengthening the education of safe medication

reinforcing the construction of information systems and arranging reasonable job allocation

medication errors can be effectively prevented.