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Martin A. Makary, MD, MPH

Arch Surg. 2007;142(3):284.

	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

The premise of health services research is that scientific advances are of no benefit if they cannot be delivered to patients. In this study of transplant medications, Friedman and colleagues demonstrate the paradigm of having the latest and most revolutionary medications within a flawed system for administering them. The result was preventable patient harm, manifested as organ rejection in 9 of 93 patients who experienced a medication error. Based on this and other recent studies, it is clear that the true confounding effect of medical errors on surgical outcomes is just beginning to be realized.

As this study reveals, both near misses and adverse events are common in surgical care. Although the authors' call for safer hospital systems is laudable, the results found in this study of transplant patients may not be representative of other surgical populations and outpatient settings. Transplant patients are unique. As . . . [Full Text of this Article]

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Medication Errors in the Outpatient Setting: Classification and Root Cause Analysis
Amy L. Friedman, Sarah R. Geoghegan, Noelle M. Sowers, Sanjay Kulkarni, and Richard N. Formica, Jr
Arch Surg. 2007;142(3):278-283.
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