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Commentary
The alarming reality of medication error: a patient case and review of Pennsylvania and national data.
November 16, 2016
da Silva BA, Krishnamurthy M. J Community Hosp Intern Med Perspect. 2016;6(4):31758.
Despite efforts to improve medication safety, it remains a persistent challenge in health care. This commentary describes an incident involving a medication error to illustrate how the Swiss cheese model can be used to explain why small missteps can result in failure. The authors review estimated incidence of medication errors at both local and national levels.
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