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Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

Washington, DC: VA Office of Inspector General. August 6, 2015. Report No. 15-02131-471.

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September 16, 2015

Washington, DC: VA Office of Inspector General. August 6, 2015. Report No. 15-02131-471.

Drug–drug interactions resulting in adverse drug events are common causes of preventable harm to patients. This investigation determined that mixed drug toxicity was the cause of a patient's death at a Veterans Affairs facility and factors that contributed to the incident included lack of teamwork, informed consent, emergency response efforts, and equipment access.