Monday, January 28, 2008

Breaking the Error Chain

'It's never just one thing' that leads to serious error
By Susan Brink
Los Angeles Times Staff Writer

January 28 2008

A technician mistakes an "a" for an "o" in a drug name. A doctor misplaces a decimal point in a prescription order. A nurse reaches for a vial in a cabinet as she's done hundreds of times before, only this time the light is dim and she fails to notice that the powder-blue label is more of a sky blue. The slip-ups are often simple, and always human, and all have happened in U.S. hospitals.

The complete article can be viewed at:,1,185313.story