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Medication/Drug Errors

Last Updated: September 6, 2022
Created By: Dr. Yan Xiao, AHRQ TEP Member

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.
Library Organization
Content Type - This library is organized by the PSNet default organization style.
Primers (2)
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS |

Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery,... Read More

Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of... Read More

All Library Content (28)
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Tobiano G, Chaboyer W, Dornan G, et al. Aging Clin Exp Res. 2021;33:3353-3361.
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.
Garfield S, Furniss D, Husson F, et al. BMJ Qual Saf. 2020;29:764-773.
This mixed-methods study of patients, caregivers and healthcare professionals explores how patient-held medication lists (such as paper medication lists, medication diaries, or apps) can support patient safety. Patient-held lists can improve medication safety by improving the accuracy of medication reconciliation, identifying potential drug interactions, and facilitating communication.
Machen S, Jani Y, Turner S, et al. Int J Health Care Qual. 2019;31:g146-g157.
This scoping review discussed how organizational and professional culture influences medication safety practices. The authors reviewed over 40 articles and identified four themes influencing medication safety: (1) professional identity, (2) fear of litigation/punishment, (3) hierarchy, and (4) pressure to conform.
Melton KR, Timmons K, Walsh KE, et al. BMC Medical Inform Decis Mak. 2019;19:213.
Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.
Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. The 2024 survey session opens April 1, 2024.
5200 Butler Pike, Plymouth Meeting, PA, 19462. 215-947-7797.
The Institute for Safe Medication Practices (ISMP) is a nonprofit organization whose focus is to help health care practitioners understand medication error from a systems perspective, collect reports of errors, and disseminate recommendations to help prevent similar occurrences.
LeBlanc RG, Choi J. Home Healthc Now. 2015;33:313-319.
Patients who receive home care services are vulnerable to adverse events, as they are generally chronically ill and take many prescribed medications. This preliminary study reports on a home care–based intervention to enhance medication safety through medication reconciliation and improving multidisciplinary communication.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24:1-6.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS |
Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.
Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.
Organizational Policy/Guidelines
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Medication safety is a concern in various settings across an organization. This white paper discusses the role of a medication safety officer to oversee reporting and analysis of medication errors and coordinate improvement efforts. Responsibilities of a medication officer include serving as a champion, advocating for safety interventions, and helping implement system changes.
MacColl Center for Health Care Innovation at the Kaiser Permanente of Washington Research Institute, University of Washington.
In light of the current opioid crisis, the use of opioids to manage noncancer-related chronic pain in the ambulatory environment has been targeted for improvement. This AHRQ-funded initiative offers a six-element multidisciplinary redesign approach that highlights areas such as leadership development, prescription monitoring, and care planning.
Plymouth Meeting, PA; Institute for Safe Medication Practices. ISSN 1550-6312.
The Institute for Safe Medication Practices' (ISMP) signature bi-weekly newsletter recounts actual experiences with medication errors reported to the ISMP. Feature articles here also present thoughtful reviews of error reduction strategies. Portions of the newsletter are available at no cost via the ISMP website.
53 State Street, 19th Floor, Boston, MA 02109. 617-301-4800,
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization promoting health improvement by advancing the quality and value of health care. Current IHI initiatives include a white paper collection, an international conference series, and an online curriculum. In May 2017, IHI merged with the National Patient Safety Foundation.
Krzyzaniak N, Bajorek B. Ther Adv Drug Saf. 2016;7:102-119.
Medication errors are prevalent in inpatient care. This narrative review compared medication errors in neonatal care with those across hospitalized pediatric, adult, and elderly patients. Common types of errors among hospitalized neonatal patients were patient misidentification and overdosing. The authors provide recommendations to improve medication safety for this vulnerable population, which includes integrating a clinical pharmacist into the direct care team.
Olaniyan JO, Ghaleb M, Dhillon S, et al. Int J Pharm Pract. 2015;23:3-20.
This systematic review found that incidence rates of medication errors in primary care ranged between 1% and 90% across included studies, suggesting that further research is needed to identify the true incidence. The authors identified most errors in the prescribing stage, and older patients and children seem to be at highest risk.
Multi-use Website
Atlanta, GA: Centers for Disease Control and Prevention.
This Web site provides information for providers and patients to reduce risks related to adverse drug events, including links to fact sheets, research, and government initiatives.
Kanaan AO, Donovan JL, Duchin NP, et al. J Am Geriatr Soc. 2013;61:1894-1899.
Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.