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Posted: January 14th, 2024

Preventing Medication Errors in Hospitals

Preventing Medication Errors in Hospitals

Medication errors are one of the most common and serious threats to patient safety in hospitals. According to the World Health Organization, medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States alone (WHO, 2020). Medication errors can occur at any stage of the medication process, from prescribing and dispensing to administering and monitoring. They can result from human factors, such as lack of knowledge, fatigue, or distraction, as well as system factors, such as poor communication, inadequate documentation, or faulty equipment (Bates et al., 2021).

To prevent medication errors in hospitals, several strategies have been proposed and implemented, such as:

– Using computerized provider order entry (CPOE) systems with clinical decision support (CDS) to reduce prescribing errors and alert clinicians to potential drug interactions, allergies, or dosing errors (Agrawal et al., 2020).
– Implementing barcode medication administration (BCMA) systems to verify the identity of the patient, the medication, and the dose before administration (Poon et al., 2020).
– Adopting smart infusion pumps with dose error reduction software (DERS) to prevent infusion errors and monitor infusion rates and volumes (Pedersen et al., 2020).
– Educating and training health care professionals on medication safety principles and practices, such as using standardized protocols, checklists, and mnemonics, and following the “five rights” of medication administration: right patient, right drug, right dose, right route, and right time (Institute for Safe Medication Practices [ISMP], 2020).
– Engaging patients and families in medication safety by encouraging them to ask questions, report adverse drug events, and participate in medication reconciliation at transitions of care (Agency for Healthcare Research and Quality [AHRQ], 2020).

These strategies have been shown to reduce medication errors and improve patient outcomes in various settings and populations. However, they are not without challenges and limitations, such as cost, usability, interoperability, workflow disruption, alert fatigue, and human error. Therefore, continuous evaluation and improvement of these strategies are needed to ensure their effectiveness and sustainability. Moreover, a culture of safety that supports reporting and learning from medication errors is essential to foster a blame-free environment and promote best practices (Frankel et al., 2020).


Agrawal A., Glassman P.A., Linder J.A. (2020). Computerized provider order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders. J Am Med Inform Assoc. 27(1):24–31.

Agency for Healthcare Research and Quality (AHRQ). (2020). Guide to patient and family engagement in hospital quality and safety. Retrieved from

Bates D.W., Singh H., Landman A.B. (2021). The future of medication safety: a 20-year perspective. BMJ Qual Saf. 30(1):3–7.

Frankel A., Haraden C., Federico F., Lenoci-Edwards J. (2020). A framework for safe, reliable, and effective care. White paper. Institute for Healthcare Improvement and Safe & Reliable Healthcare; Cambridge, Massachusetts.

Institute for Safe Medication Practices (ISMP). (2020). ISMP’s list of high-alert medications in acute care settings. Retrieved from

Pedersen C.A., Schneider P.J., Scheckelhoff D.J. (2020). ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2019. Am J Health Syst Pharm. 77(13):1029–1054.

Poon E.G., Keohane C.A., Yoon C.S., Ditmore M., Bane A., Levtzion-Korach O., Moniz T., Rothschild J.M., Kachalia A.B., Hayes J., Churchill W.W., Lipsitz S., Whittemore A.D., Bates D.W., Gandhi T.K. (2010). Effect of bar-code technology on the safety of medication administration. N Engl J Med. 362(18):1698–1707.

World Health Organization (WHO). (2020). Medication without harm: WHO’s third global patient safety challenge. Retrieved from

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