How Medication Errors Happen in a Hospital Setting

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Important new research has been recently published in the American Journal of Health-System Pharmacy by the American Society of Health-System Pharmacists, Inc. The research study is entitlted Health Care System Vulnerabilities: Understanding the Root Causes of Patient Harm.
The publication is significant in that it goes a step beyond the extant research and examines how adverse drug events in a hospital actually take place. The authors trace patients’ entrance into the emergency room and follow the patients through discharge and re-admission. Their findings should prove very helpful in determining the root causes of medication errors and adverse drug events.
The authors explain the goal of their research in the Introduction, “There is an abundance of literature evaluating ADEs at various points of a patient’s transition across the health care continuum; however, literature surveying the prevalence of ADEs across the full spectrum of care is lacking. This article explores potential vulnerabilities of the health care system as we track a patient’s movement from his arrival at the emergency department (ED) through admission and transfer to the intensive and acute care units and to the patient’s hospital discharge.”

Eva Bleich
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