Evidence that medication errors occur commonly in all patient care settings continues to mount. Kozer et al demonstrate in this issue of Pediatrics that the pediatric emergency department (ED) is no exception, with errors noted in 10.1% of records during a 12-day study period. As the authors point out, this error rate almost certainly is an underestimate of the magnitude of the problem, because the study was a retrospective chart review. For example, errors intercepted before an order actually was written and errors occurring while dispensing or administering drugs would not have been detected by the methodology used by the investigators. Although only 2 errors were “severe” (had the potential to cause death or decrease chances of successful treatment of a life-threatening condition), this translates into >100 “severe” mistakes annually in just 1 ED. Moreover, nearly half of the errors were “significant” and could have had important clinical consequences....

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