Promoting Patient Safety:
Avoiding Medication Errors
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An estimated 25% of all adverse drug events (ADEs) are preventable (ie, result from medication errors). Although less than 1% of medication errors cause harm, it has been estimated that medication errors harm at least 1.5 million people and result in more than 7,000 deaths in the US every year. Medication errors that occur in the outpatient setting cost the US healthcare system an estimated $4.2 billion annually. And this amount is dwarfed by the estimated cost of medication errors that occur in hospitals – approximately $16.4 billion per year. At least 400,000 preventable ADEs occur in hospitals every year.
A medication discrepancy can be defined as any difference between a patient’s prescribed medications and the patient’s actual use of the medications. Both healthcare system factors (eg, faulty medication reconciliation) and patient-related factors (eg, nonadherence) contribute to medication discrepancies. One study of older adults who were discharged from the hospital to home found that 94% had at least 1 discrepancy between their discharge medication lists and actual medication use at home. Improving transitional care for patients being discharged from hospital to home has been consistently linked with lower readmission rates and reduced health care costs. Healthcare team members can play a crucial role in improving patient safety by helping patients avoid medication errors and discrepancies.
This article discusses the nature of medication errors and preventable ADEs, and their impact on patient and health-system outcomes. Risks associated with transitions in care, and health information technology (HIT) approaches to improve medication safety, are also presented.
Publication Date: 11/20/2014
Expiration Date: 11/20/2017
CE Credit: 1.5 (0.15 CEU)
Type of Activity: Knowledge-based
This program was developed by The Rx Consultant and published by Continuing Education Network, Inc.
The Rx Consultant accepts no advertising or financial support from the pharmaceutical industry and
is funded solely by the purchase of programs. The Rx Consultant is dedicated to providing unbiased,
balanced information to health care practitioners.
Programs developed by The Rx Consultant are written by health care providers with expertise in the topic
area, peer-reviewed, extensively edited, and fact-checked. This development process was created to insure
that every program presents information that is current, accurate, relevant to "real world" health care
providers, and written in an easy reading, "plain English" style.
Joshua J. Neumiller, PharmD, CDE, FASCP is a Consultant Pharmacist and an Associate Professor of Pharmacotherapy at Washington State University (WSU). Dr. Neumiller is a member of WSU’s Geriatrics Team and WSU’s Clinical Trials Research Team. Dr. Neumiller is actively involved in research aiming to improve medication safety during care transitions for older adults and clinical trials centered on the management of diabetes and its complications.
Dr. Neumiller reports no financial or personal relationship with any commercial interest producing, marketing, reselling, or distributing a product or service that appears in this issue.
This accredited program is targeted to
Goals & Objectives
At the conclusion of this program, participants will be able to:
- Define the terms “medication error” and "adverse drug event", and describe their relationship. List factors that contribute to medication errors in the community setting.
- Name 3 drugs/classes that are commonly implicated in serious medication errors. List ways to reduce prescribing errors and dispensing errors.
- Discuss the occurrence and prevention of medication errors during care transitions. Discuss medication adherence in the home setting.
- Outline potential benefits and limitations of health information technology, including e-prescribing.
The Rx Consultant is a publication of Continuing Education Network, Inc.
Continuing Education Network, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education as a
provider of continuing pharmacy education.
Continuing Education Network is approved by the California Board of Registered Nursing, Provider Number CEP 13118. Programs approved by CA BRN are accepted by most State Boards of Nursing.
ACPE Universal Activity Number: 0428-0000-14-015-H05-P
Exam & Credit Statement Procedures
Upon successful completion of this program and the post test (70%), 1.5 hours of continuing education credit will be awarded. To receive credit and your exam score, please complete the exam questions and
Editorial and Review Board
Chief Editor and CE Administrator
Terry M. Baker, PharmD
Tracy Farnen, PharmD
James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Associate Clinical Professor
School of Pharmacy
University of California San Francisco
San Francisco, CA
Richard Ron Finley, B.S. Pharm.,R.Ph.
Clinical Pharmacist (volunteer faculty)
University of California, San Francisco (UCSF) Memory and Aging Center
Lecturer (Emeritus) UCSF, Department of Clinical Pharmacy
Health Sciences Clinical Professor, UCSF School of Pharmacy
San Francisco, CA
Ray Dolby Brain Health Center, Sutter Health/CPMC
San Francisco, CA
Consult Pharmacist Aging and Adult Health Services
San Francisco Health Department
San Francisco, CA
Julio R. Lopez, PharmD, FCSHP
Chief of Pharmacy Service
VA Northern California Health Care System
Adjunct Clinical Professor
College of Pharmacy
Assistant Clinical Professor
School of Pharmacy
University of California, San Francisco
San Francisco, CA Adjunct Professor
Thomas J. Long School of Pharmacy
University of the Pacific
Visiting Associate Professor and Lecturer
Samuel Merritt University
Pamela Mausner, MD
Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Senior Editorial Advisor
Gerard Hatheway, PharmD, PhD
Belinda M. Danielson, RPh
Christopher M. DeSoto, PharmD
Angie S. Graham, PharmD
Cynthia Chan Huang, PharmD, MBA
Fred Plageman, PharmD
Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners
Meuleman, RN, C, MS
About the Rx Consultant
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educate patients about drugs and manage drug therapy. The reader is responsible for confirming
the information presented here and interpreting it in relation to each patient's specific situation before utilizing the information.
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