Abstract
1The 297 passengers and 12 crew all survived, and only minor injuries were sustained. At least 30 investigators from the Canadian Transportation Safety Board have been investigating the crash. 1 The effects of medication errors have often been compared to those of a plane crash since the number of medication-related deaths that occur annually in our health care system is comparable to the number resulting from many typical plane crashes. However, because fatal medication errors occur at many different sites, they are not subjected to the same quality assurance checks and improvements that society routinely expects after a plane crash. The health care community has been inundated with medication error reports for years, but the 1999 Institute of Medicine report 2
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