The errors often occur in the transfer of information.

There were actually more than 950 different medications recorded in these error reports.

Whenever a patient is moved from one location to another, the patient should ask where they are going and why. Our report shows this is when the risk is particularly great.

That means that the patient either ended up with permanent harm or the error caused the patient to receive some sort of heroic intervention necessary to save life, such as CPR (cardiopulmonary resuscitation) or surgery.