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Anne-Marie J. Audet, MD,MSc; Erin E. Hartman, MS

JAMA. 2002;287:3258.

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

In a Clinical Crossroads article published in June 2001, David W. Bates, MD, MSc, discussed a 40-year-old woman, Ms K, who encountered a medication error in the course of outpatient care.¹ Incorrect medications—Stelazine (trifluoperazine hydrochloride) and ranitidine—were dispensed instead of stavudine and lamivudine. Ms K was fortunate because she noticed the error and was able to correct it and continue her antiretroviral medications uninterrupted.

Dr Bates reviewed the epidemiology of medication errors, pointing out that more is known about errors in inpatient than outpatient care. He mentioned that among the many causes of errors, drug names that sound alike are the most common. Dr Bates suggested that drug safety will be fully realized only when prescriptions can be sent electronically to the pharmacy site, reducing handling by different people during the process. Dr Bates stressed that health care providers must focus on . . . [Full Text of this Article]

MS K, THE PATIENT