Medication Errors Observed in 36 Health Care Facilities

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Abstract
THE 1999 Institute of Medicine report1 on the quality of care, entitled To Err Is Human: Building a Safer Health System, has drawn national attention to the occurrence, clinical consequences, and cost of adverse drug events (ADEs) in hospitals. The report calls for more systematic approaches to the prevention of injuries due to medical care. Many of these ADEs are viewed as originating from systems problems (ie, problems with the processes of the medication use system). We divide those processes into (1) prescribing and (2) delivery and administration. The focus of this article is on the latter.

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