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PSNet: Patient Safety Network
Journal Article

Non–health care facility medication errors resulting in serious medical outcomes.

Hodges NL, Spiller HA, Casavant MJ, et al. Clinical toxicology (Philadelphia, Pa.). 2018;56:43-50.

Medication errors that occur in health care settings have been well described, but less is known about medication errors that take place in non–health care settings. In this retrospective study, researchers analyzed data from the National Poison Database System. Over a 13-year study period, 67,603 unintentional medication errors that resulted in serious medical outcomes occurred outside the health care setting. The study found an average rate of these types of medication errors of 1.73 per 100,000 people. Death was reported in 0.6% of cases. In keeping with prior research, the most frequently reported types of medication errors included dosing and administration errors. A previous WebM&M commentary described a near miss in which a patient almost administered the wrong medication to himself after hospital discharge.