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	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

We welcome the research of Barker and colleagues¹ into medication errors arising in hospital settings. They emphasize the importance of dosage errors, the second largest source of errors. Dosage errors can occur, however, not just at the time of drug administration, but also during the calculation and preparation of treatment.

Observing the behavior of subjects as they undertake their tasks has been shown to introduce bias—the Hawthorne effect.² This may explain why, in 2 units, Barker et al¹ found no errors, especially since those units were also being assessed for accreditation during the period of the study. We and our colleagues conducted a study³ to detect errors in the giving of acetylcysteine to patients with paracetamol (acetaminophen) poisoning. In the United Kingdom this drug is given by intravenous infusion of 3 sequential doses that depend on body weight. Our study avoided direct observation: nurses and pharmacists who prepared bags for . . . [Full Text of this Article]

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Medication Errors Observed in 36 Health Care Facilities
Kenneth N. Barker, Elizabeth A. Flynn, Ginette A. Pepper, David W. Bates, and Robert L. Mikeal
Arch Intern Med. 2002;162(16):1897-1903.
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