Preventable adverse drug events (ADEs) generate an estimated $2 billion in direct hospital costs each year and are a substantial source of morbidity and mortality.1 The 2 processes from which preventable ADEs most commonly arise are medication prescribing and administration. A physician order for penicillin for a patient with a known penicillin allergy is an example of the former, whereas the latter is illustrated by the erroneous administration of 100 units of insulin when 10 were ordered. There has been considerable attention devoted to reducing prescribing error with systematic solutions such as computerized physician order entry, electronic decision support, and pharmacist presence during physician rounds. None of these solutions, however, reduces medication administration errors, which account for 34% of preventable ADEs.2
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