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David W. Bates, MD,MSc, Discussant

JAMA. 2001;285:3134-3140.

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

INTRODUCTION

DR AUDET: Ms K is a 40-year-old woman who found an error with her prescribed medications. She was diagnosed with HIV infection in 1996 and has taken several different drug regimens. Despite the complexity of her drug program, Ms K has been able to manage it well. She has taken an active role in understanding the benefits of her medications and has not had major adverse effects.

Ms K had asked that refills for her prescriptions be called in to her pharmacy. When the time came to take her newly filled prescriptions, she noted that 2 of the drugs were unfamiliar to her, and that 2 of her HIV drugs were missing.

Ms K immediately called her primary care physician, Dr T, to report this fact and have the error rectified. She was concerned about continuing her planned HIV regimen without interruption. The error was . . . [Full Text of this Article]

MS K: HER VIEWS

DR T: HER VIEWS

AT THE CROSSROADS: QUESTIONS FOR DR BATES

Systems Analysis of the Case

Today's Medication Process

Epidemiology of Medication Errors

Effect of Setting

Risk Factors for ADEs

Causes of Errors

Prevention Strategies

Medication Errors and the Public

Strategies to Reduce Error: The Refill System

Conclusions

QUESTIONS AND DISCUSSION

Author Affiliation: Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, and the Center for Applied Medical Information Systems Research, Partners HealthCare System, Boston, Mass.

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