Medication Errors in Hospitals–-It's Everyone's Fault

JAMA Performance Improvement: Do No Harm
20/06/2017 18 min
Medication Errors in Hospitals–-It's Everyone's Fault

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Episode Synopsis

A patient was admitted to the hospital and got three times their normal dose of phenytoin resulting in phenytoin toxicity and a long hospital stay. Analysis of the error revealed problems with hospital organization, supervision issues and having an environment that facilitates errors. Errors don't occur simply because one clinician makes a mistake—rather they occur because the hospital system fails to prevent them. Related article: Phenytoin Toxicity—A Significant Adverse Drug Event

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