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January 17, 1966

Hospital Medication Errors

JAMA. 1966;195(3):31-32. doi:10.1001/jama.1966.03100030013003

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A resident in hospital pharmacy in a state university teaching hospital chanced one day to observe a nurse carry two hypodermic syringes into a room with four patients. One syringe was filled with papaverine and the other contained procaine penicillin G. The nurse proceeded to give both injections to the wrong patients.

The incident led to a series of carefully constructed studies designed to answer a question of major import to physicians:

Once a medication is ordered in the hospital, does the right drug get into the right patient, in the right amount, in the right way, and at the right time?

Frequently, the studies suggest, the answer is no.

One in Seven  Reporting at the recent meeting in California of the American Association for the Advancement of Science, Kenneth Barker, MSP, said that observations in a 300-plus bed general hospital indicate such errors may occur as often as once

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