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Cases & Commentaries
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Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.
The author, who lost his brother to medical error, reflects on his family's frustrating experience with the hospital and legal system. He proposes that the medical profession can learn valuable lessons from the engineering safety culture.