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April 12, 1995

Human Error in Medicine

Author Affiliations

University of California San Diego

JAMA. 1995;273(14):1156. doi:10.1001/jama.1995.03520380092046

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I can remember my first "error." It might not be the first mistake that I made as a clinician, but it is the first I remember where I saw the immediate cause and deadly effect. The truth is that even on the day it happened I realized that I might not be to blame and certainly should not carry the sole burden. On the order of my resident we dialyzed a critically ill patient and failed to re-administer an antibiotic. Within a few hours the patient was dead. We never ascertained whether the death was a result of the lack of antibiotic or whether the multisystem organ failure was too much for the frail body. Still, with that experience I realized how potentially deadly any one of our decisions might be. There was an error, that is certain. Whether the error caused harm is unknown. It is clear, however, that

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