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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.

Disclosure Statement

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.

Target Audience

This accredited program is targeted to pharmacists .

Goals & Objectives

At the conclusion of this program, participants will be able to:

    1. Define the terms “medication error” and "adverse drug event", and describe their relationship. List factors that contribute to medication errors in the community setting.

    2. Name 3 drugs/classes that are commonly implicated in serious medication errors. List ways to reduce prescribing errors and dispensing errors.

    3. Discuss the occurrence and prevention of medication errors during care transitions. Discuss medication adherence in the home setting.

    4. Outline potential benefits and limitations of health information technology, including e-prescribing.

Accreditation Statements

The Rx Consultant is a publication of Continuing Education Network, Inc.

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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.

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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 program evaluation.

Editorial and Review Board

Chief Editor and CE Administrator

Terry M. Baker, PharmD

Managing Editor

Tracy Farnen, PharmD

Associate Editors

James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Kaiser Permanente
Oakland, CA

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

Consultant Pharmacist
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
Touro University
Vallejo, CA

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
Stockton, CA

Visiting Associate Professor and Lecturer
Nursing School
Samuel Merritt University
Oakland, CA

Pamela Mausner, MD

Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Detroit, MI

Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Detroit, MI

Senior Editorial Advisor

Gerard Hatheway, PharmD, PhD

Editorial Advisors

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

Emily K.
Meuleman, RN, C, MS

About the Rx Consultant

The Rx Consultant is a monthly publication dedicated to providing health care professionals with the information they need to 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.

Technical Specifications

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Browser that supports TLS 1.1 + and PDF files.

This includes Microsoft Internet Explorer 11, Google Chrome 38, Google Android OS 5.0 Browser, Apple Safari (version 7 for desktop, 5 for mobile), Mozilla Firefox 27, newer versions of these browsers, as well as some earlier versions that may require additional configuration.

Adobe Acrobat Reader is recommended, and is required for some browsers.

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