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It has been proposed that ônear missesö or ôclose callsö could serve as a focus for corrective action. Voluntary anonymous error data were collected for 4 weeks and 235 events were reported: 168 were near misses and 67 resulted in adverse patient consequences. Of the 35 errors relating to diet, 17 (49%) resulted in adverse patient consequences compared with only 5 of 43(12%) of the errors related to medication. |
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