Patients enrolled in hospice care are generally elderly and may use high-risk medications, such as opioids and sedatives. These factors have been associated with serious medication errors in prior studies. However, little is known about medication errors in hospice patients. In this study conducted in two hospice organizations, clinical personnel received an educational seminar designed to encourage voluntary reporting of adverse drug events. The intervention resulted in improved understanding of medication errors and increased error reporting (at one of the two sites). Prior studies have also successfully increased error reporting rates but, as a recent commentary notes, incident reporting itself may not improve safety unless reported incidents are rigorously analyzed and followed up.

In this perspective, the author discusses how the organizational culture of the US Food and Drug Administration (FDA) must change to foster a culture of safety.