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Clinical Crossroads
June 27, 2001

A 40-Year-Old Woman Who Noticed a Medication Error

Author Affiliations

Author Affiliation: Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, and the Center for Applied Medical Information Systems Research, Partners HealthCare System, Boston, Mass.


Clinical Crossroads Section Editor: Margaret A. Winker, MD, Deputy Editor.

JAMA. 2001;285(24):3134-3140. doi:10.1001/jama.285.24.3134

DR AUDET: Ms K is a 40-year-old woman who found an error with her prescribed medications. She was diagnosed with HIV infection in 1996 and has taken several different drug regimens. Despite the complexity of her drug program, Ms K has been able to manage it well. She has taken an active role in understanding the benefits of her medications and has not had major adverse effects.

Ms K had asked that refills for her prescriptions be called in to her pharmacy. When the time came to take her newly filled prescriptions, she noted that 2 of the drugs were unfamiliar to her, and that 2 of her HIV drugs were missing.

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