AbstractThe process of giving medication in an acute care hospital is an example of chaos
principles. Each medication order, dispensing, administration and monitoring, and evaluation is
unique. Each patient situation and concurrent medical problems is unique. Each person in the
process of dispensing, administering, monitoring, and evaluation is unique. This sets up
thousands of variables in interaction with medication administration. Because these variables are
highly dependent on communication and human behavior, the outcome is that patient deaths
occur. These problems were first highlighted by Kohn, Corrigan, and Donaldson (1999) in a
report published in the Institute of Medicine’s (IOM). The challenges of making medication
administration safer are even more acute in the rural hospital environment because resources are
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