ASHP Guidelines on Preventing Medication Errors in Hospitals

The goal of medication therapy is the achievement of defined therapeutic outcomes that improve a patient’s quality of life while minimizing patient risk.1 There are inherent risks, both known and unknown, associated with the use of medications (prescription and nonprescription). This document addresses medication errors, defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.2 The landmark Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System, published in 1999, increased the national focus on improvements and the prevention of errors in patient safety.3 This report drew attention to the significant problem of medical errors in the healthcare system, one type of which is medication errors. Other reports published after 1999 have drawn attention to patient safety improvement efforts, including 5-, 10-, and 15-year updates after To Err Is Human,4,–6 as well as the 2007 release of IOM’s Preventing Medication Errors: Quality Chasm Series.7 While the original IOM report increased awareness of the significant risk of medical errors, the pace of change is slow, and there is more work to be completed.6