Mitigating Medication Mistakes

Wrong dosage. Missed contraindication alerts. Incorrect drug. Medication errors are diverse and pervasive risks in health care delivery. The many touchpoints related to medications in the clinical setting translate into a high level of vulnerability to error. According to Candello’s national malpractice case database, medication errors accounted for six percent of all malpractice claims closed between 2014–2023. These mistakes span the entire medication process of care, highlighting the critical need for vigilance and prevention at every step.

Medication Management

Medication management is an ongoing process starting when a patient first receives medication up to the point when it’s no longer needed. This cycle can span years, depending on treatment complexity. Our data show management errors carried the most significant clinical and financial risks in the medication process of care. Ensuring a thorough medication reconciliation process, especially during transitions of care and clinical handoffs, can be an effective strategy to help reduce medication-related risks.

Ordering

Ordering errors can occur from the moment a health care provider prescribes medication until the pharmacy receives the order. Even though computerized prescriber order entry (CPOE) systems have improved the quality of care, these new technologies introduce different system and user risks.

Dispensing

Dispensing errors, defined as mistakes made from the time a pharmacy receives an order until the medication reaches the patient, are less frequent than other steps in the care process. 

Administration

Administering the right medication, dose, route, and timing to the correct patient is paramount to treatment, and errors here can lead to severe outcomes. For instance, in one tragic case, a nurse mistakenly administered norepinephrine instead of an antibiotic, resulting in the patient’s death.

Other Medication-Related Risks: Expect the Unexpected

This category covers unpredictable events, such as adverse reactions from unknown allergies despite proper medication ordering and administration. These scenarios emphasize the need for vigilant monitoring and thorough documentation to quickly address unexpected reactions.

Collaborative Prevention, Technology, and Teamwork

Even though robust technological solutions have improved patient safety in many ways, safe medication therapy requires collaboration and a transparent safety culture. Actively involving pharmacists in clinical decision-making, committing to regular professional development, and strengthening interdisciplinary communication significantly reduce risks. Continuously optimizing patient engagement and education strategies can also positively influence medication adherence and safety. Moreover, the horizon is expanding with AI-driven tools that promise additional safeguards across the medication process—but adopting these technologies brings new training demands and protocol development to ensure they bolster, rather than complicate, patient safety.

Explore these real-world medication malpractice case studies for deeper insights: