Preventing Medication Errors: A $21 Billion Opportunity.

Fact Sheet/FAQs

Preventing Medication Errors: A $21 Billion Opportunity.

February 16, 2011

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.

Free full text (PDF)

Related Resources From the Same Author(s)

Safe Practices for Better Healthcare: 2010 Update.

April 21, 2010

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

December 3, 2008

The Power of Safety: State Reporting Provides Lessons in Reducing Harm, Improving Care.

July 7, 2010

Patient Safety Measures: Complications.

January 30, 2005

Safe Practices for Better Healthcare–2009 Update.

March 18, 2009

Patient Safety 2015: Final Technical Report.

November 12, 2014

Standardizing a Patient Safety Taxonomy.

February 22, 2006

Serious Reportable Events in Healthcare—2011 Update.

May 30, 2007

Identification and Prioritization of Health IT Patient Safety Measures.

March 16, 2016

National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report.

June 27, 2012

Antibiotic Stewardship in Acute Care: A Practical Playbook.

July 13, 2016

The Care We Need

July 8, 2020

Safe Practices for Better Healthcare: 2006 Update.

March 6, 2005

Patient Safety Measures.

December 11, 2013

Improving Diagnostic Quality and Safety Final Report.

September 27, 2017

Advancing Anticoagulation Stewardship: A Playbook.

September 7, 2022

Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy.

September 28, 2005

Compendium of Reports.

May 31, 2006

National Action Plan to Improve Health Literacy.

June 16, 2010

The Role of Human Factors in Home Health Care: Workshop Summary.

November 10, 2010

The Safe Use Initiative and Health Literacy: Workshop Summary.

December 15, 2010

When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"?

April 27, 2016

Quality and Safety in Women's Health Care. Second Edition.

October 20, 2010

Patient Safety Act.

February 10, 2010

Announcing 2009 Leapfrog top hospitals.

December 16, 2009

Clinician Well-Being Knowledge Hub.

April 4, 2018

NAM Action Collaborative on Clinician Well-Being and Resilience.

February 15, 2017

Improving Diagnostic Accuracy Project 2016–2017.

October 19, 2016

Patient Safety Project 2015–2017.

January 27, 2016

Ambulatory Care Patient Safety 2017–2018.

November 22, 2017

Patient Safety Collaboration.

November 27, 2013

20 Years After “To Err is Human”, Leapfrog Hospital Safety Grades Prove Transparency Can Save Lives.

November 20, 2019

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

Safety Assurance Factors for EHR Resilience: SAFER Guides.

January 29, 2014

The Future of Nursing: Leading Change, Advancing Health.

March 31, 2011

Adverse Events in Hospitals: Public Disclosure of Information About Events.

January 20, 2010

Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report

October 28, 2020

Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations.

December 11, 2019

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

July 27, 2016

Communicating Clearly About Medicines: Proceedings of a Workshop—in Brief.

May 31, 2017

Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.

May 12, 2021

Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief.

May 11, 2022

Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief.

September 7, 2021

Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief.

October 5, 2021 - October 6, 2021

The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety.

October 19, 2011

Building the Case for Health Literacy: Proceedings of a Workshop.

August 8, 2018

Communicating Clearly About Medicines: Proceedings of a Workshop.

September 20, 2017

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

November 15, 2023

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.

November 6, 2019

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

February 9, 2011

Health IT Safety Center Roadmap.

July 29, 2015

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.

August 2, 2017

The Joint Commission and National Quality Forum Announce 2023 Eisenberg Award Recipients.

February 21, 2024

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.

January 15, 2014

Patient Safety as an Exercise in Behavioral Change.

October 24, 2012

Facilitating Patient Understanding of Discharge Instructions: Workshop Summary.

December 17, 2014

To Err Is Human: Building a Safer Health System.

March 27, 2005

Final Report of the Commission on Care.

August 3, 2016

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

August 10, 2022

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Medication Management: Detailed Use Case.

July 4, 2007

Patient Safety, Spring 2019 Final CDP Report.

March 25, 2020

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Health Care Comes Home: The Human Factors.

August 3, 2011

Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings.

September 11, 2013

The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy.

September 20, 2006

Partnership for Patients.

April 13, 2011

The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.

July 1, 2019

Core Entrustable Professional Activities for Entering Residency.

August 6, 2014

Improving Diagnosis in Health Care.

September 23, 2015

Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.

January 16, 2019

First, Do No Harm: Marshaling Clinician Leadership to Counter the Opioid Epidemic.

October 4, 2017

Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.

July 19, 2017

Professional Conduct Toolkit.

February 9, 2011

Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.

October 24, 2018

Artificial Intelligence in Health Care: The Hope, the Hype, the Promise, the Peril.

December 1, 2019

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Complexity and the Adoption of Innovation in Health Care.

March 6, 2005

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

July 20, 2011

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary.

July 27, 2011

Safer Together Annual Report.

November 21, 2023

New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings.

May 21, 2014

Coordination Between Emergency and Primary Care Physicians.

April 20, 2011

FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.

April 30, 2014

Crossing the Quality Chasm: A New Health System for the 21st Century.

March 27, 2005

The Commonwealth Fund Quality Improvement Colloquium: Patient Safety Five Years After To Err Is Human.

March 27, 2005

Health IT and Patient Safety: Building Safer Systems for Better Care.

November 16, 2011

Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation.

August 13, 2014

Keeping Patients Safe: Transforming the Work Environment of Nurses.

May 11, 2005

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

September 25, 2013

How Can Health Care Organizations Become More Health Literate?: Workshop Summary.

August 15, 2012

How to Identify and Address Unsafe Conditions Associated With Health IT.

December 18, 2013

Related Resources

Annual Perspective

Communication During Transitions of Care

March 27, 2024

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

ISMP's List of High-Alert Medications in Acute Care Settings.

January 14, 2024

Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review.

November 1, 2023

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

September 13, 2023

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

August 30, 2023

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

June 28, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

The impact of medication reconciliation and review in patients using oral chemotherapy.

March 1, 2023

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Medication errors: the year in review: January through December 2021.

January 11, 2023

WebM&M Cases

Challenges of Diabetes Management and Medication Reconciliation

August 5, 2022

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

June 29, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Medication errors' causes analysis in home care setting: a systematic review.

February 9, 2022

Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk.

November 11, 2020

Intervention study for the reduction of medication errors in elderly trauma patients.

September 2, 2020

Pharmacist-led program to improve transitions from acute care to skilled nursing facility care.

July 8, 2020

Measuring the impact of medication-related interventions on 30-day readmission rates in a skilled nursing facility.

July 1, 2020

Impact of a pharmacist-administered deprescribing intervention on nursing home residents: a randomized controlled trial.

July 1, 2020

WebM&M Cases

Life-Threatening Infant Overdose of Sodium Chloride

May 27, 2020

Annual Perspective

Pharmacist Role in Patient Safety

February 21, 2020

Pharmacist linkage in care transitions: from academic medical center to community.

October 30, 2019

10 Medication Safety Tips for Hospitalized Patients.

September 25, 2019

Individual and team-based medical error disclosure: dialectical tensions among health care providers.

August 28, 2019

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Pharmacy

Medication Errors/Preventable Adverse Drug Events

Active Errors