Nurses and other health care workers have long known from experience that mistakes in patient care are not uncommon.
Handwritten prescriptions are misread.
Inappropriate doses are erroneously administered. Specialists in different departments work at cross purposes and fail to communicate. The list goes on. The scope of the problem may surprise even the most seasoned practitioner. Ten years ago, the Harvard Medical Practice Study reported that 3.7 patients out of every 100 hospital admissions suffered an adverse event.