Medication Safety

The Food and Drug Administration (FDA) estimates that there are over 1 million people injured by medication errors annually in the U.S. (Hayes, 2017). In the 2013 Forbes article titled “The Shocking Truth about Medication Errors,” author Leah Binder states, “Medication errors happen all the time, an estimated one million each year, contributing to
7,000 deaths. On average, there is one medication error every day for every inpatient.”

Healthcare providers must understand that prevention of medication errors is a large part of patient safety. This bulletin provides an overview of different types of medication errors and offers some best practices to help healthcare providers prevent medication-related mistakes and the harmful consequences that may result.

Consider the following situations and best practices to help prevent medication errors.

Errors by Medication Administration
Errors can result from the administration of a dose that was not ordered, administration of a drug in a different form from what was ordered, and through inappropriate procedure for administration, such as crushing an extended release tablet.

Errors by Omission
Medication omissions occur when a medication is not provided to a patient because it has not been administered and/or it has not been prescribed. These errors can take place throughout any stage of the medication-use process, including initial medication list, transcription miss, and pharmacy oversite (Grissinger & Alghamdi, 2017). Another common medication error is failing to administer the medication in a timely manner, within 30 minutes before or after the scheduled time. Although an omission often causes no immediate threat to the patient, it can cause delay in pain and symptom management,
increase in patient stay, risk of sepsis, and even death.

Errors by Near Miss
A near miss is a dispensing error that is discovered and intercepted prior to reaching the patient. It means that the potential cause of harm does not result in harm. Commonly in healthcare, the clinician is not aware that the near miss error has occurred. When discovered, reporting the near miss will help the organization identify the events leading up to the error. This in turn will help patients by reducing the risk of future errors.


Provider Controls

  • It is critical that clinicians adhere to the “5 Rights” of medication administration: right patient, right drug, right dose, right route, and right time (CDC, 2010).
  • Become familiar with what is prescribed and dispensed. Know high-risk medications and use necessary precautions. Use generic names when possible.
  • Medication reconciliation is important to the administration and patient care process. Ensure all currently used and/or prescribed medications have been listed. This includes over the counter (OTC) drugs, herbal supplements, and medicated lotions. This will ensure that drug-to-drug interactions are avoided.
  • Provide the patient and family educational handouts of the medications they are taking and assess their level of understanding, adjusting verbiage accordingly.
  • When the patient/family is self-administering medication, conduct a detailed demonstration of administration and ask for a return demonstration. Provide education on potential side effects of any new medications as well as side effect reminders of current medications. Educate the patient/family on preparing a daily pillbox and the importance of medication adherence. Help them create a log of when the medication was taken as well as the associated outcome.
  • Create an environment of safety. Ensure there are no interruptions while administering/preparing medication and avoid distractions.


Medication diversion is the misuse of controlled substances and medications used for pain management. It is common in healthcare practice that a patient and/or family are involved with medication abuse. Diverters often attempt to obtain medication under false pretenses, which may include illicit drug sales, and/or feeding their personal addiction. Medication safety goes beyond patient administration. Controlled substance (CS) diversion in health systems can also lead to serious patient safety issues, harm to the diverter, and significant liability risk to the organization (Brummond et al, 2017). Diversion due to addiction puts the patient at risk of harm and presents regulatory and legal risks to the organization. It also leads to inadequate pain relief, inaccuracies in documentation of care, exposure to infectious diseases from contaminated drugs and needles, as well as impaired healthcare worker (HCW) performance (Berge et al., 2012).

In hospice and home health, drug diversion is not unheard of as the patient services are likely in their home settings and the patient and/or families are responsible for their medication management. In these settings, adherence to medication policies and procedures, including patient accountability, is crucial.


Provider Controls

  • Conduct and document medication counts during each visit to help minimize diversion and increase quality of care. This procedure will give the clinician the ability to identify an issue and ensure the patient has adequate supplies of their medication.
  • Review the storage and security of medications and ensure there are internal pharmacy controls for administering and prescribing controlled substances. Additionally, review and monitor medication returns, disposal of medications, and wasting of medication. Ensure witnesses are present for these action items.


Medication safety must be a priority for healthcare providers. Medication errors can result in harm to the patient, unnecessary hospital admissions, increased length of hospital stays, and significant liability risks to the organization. Healthcare providers must take precautions to prevent errors in the administration, omission, and diversion of medications as well as the near miss of a medication error. Ensure that assessment and evaluation of drug administration, client education, and documentation are present. Additionally, ensure that errors are reported per individual organization policy and procedures.


Berge, K. H., Dillon K. R., Sikkink, K. M., Taylor, T. K., & Lanier, W. L. (2012). Diversion of drugs within healthcare facilities, a multiple-victim crime:
patterns of diversion, scope, consequences, detection, and prevention. Mayo Clinic Proceedings 87(7), 674-82.
Binder, L. (2013). The shocking truth about medication errors. Retrieved from
Brummond, P. W., Chen, D. F., Churchill, W. W., Clark, J. S., Dillon, K. R., Dumitru, D., ... & Jurakovich, K. (2017).
ASHP guidelines on preventing diversion of controlled substances.
Grissinger, M. & Alghamdi, D. (2014). Omission of high-alert medications: a hidden danger. Pennsylvania Patient Safety Advisory 11(4).
Retrieved from:
Centers for Disease Control & Prevention. (2010). Medication Safety Basics. Retrieved from:

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