Culture of Safety Reduces Medication Errors

A decade ago, the Institute of Medicine (IOM) reported that up to 98,000 patients died needlessly every year because of preventable medical errors. The report estimated the cost of these errors at $17 billion to $29 billion a year. Medication errors, in particular, accounted for a significant portion of the errors. By some estimates, 1.5 million preventable medication errors cost hospitals up to $3.5 billion a year. More than 25,000 drug errors reportedly resulted just from look-alike and sound-alike drugs during a 4-year span.

To help reduce errors and promote safety, The Joint Commission rolled out its National Patient Safety Goals program in 2002. This program was designed to help organizations address specific concerns regarding patient safety. 

For example, Patient Safety Goal 3 focuses on improving the safety of using medications. It mandates that healthcare organizations review a list of look-alike and sound-alike medications and act to prevent mix-ups. It also expects organizations to label all medications and containers and to reduce the harm associated with anticoagulant therapy. Patient Safety Goal 8, medication reconciliation, will address ways to ensure that medications are not overlooked when patients move between the home and healthcare facilities.

Down with Blame, Up with Safety

To meet the challenges of reducing medical errors and promoting safe medication administration, many organizations are making a paradigm shift from a culture of error and blame to a culture of safety. 

In the past, facilities hesitated to disclose errors for fear of litigation. They took a “blame and shame” approach toward the healthcare professionals involved and held them personally accountable despite the fact that many patient safety problems are systems-based and beyond any individual’s control. Fear of disciplinary action was expected to maintain safety, but the same fear prevented many errors from being reported. 

This culture of error and blame became self-defeating: Errors were underreported, so the facilities had no opportunity to review them and improve on existing systems.

To push past this culture of error, healthcare organizations have begun to openly disclose and evaluate errors in a culture of safety. With this new approach, healthcare professionals can admit and discuss errors without fear of retribution. The focus has shifted toward preventing errors and creating a safe environment, where problems can be discussed and resolved. 

According to Sherry Shaffer Ratajczak, RN, MSN, CRNP, Clinical Editor at Elsevier | MC Strategies, “Many nurses fear that reporting a medication error will result in a loss of their job, or worse, a loss of their license. However, in a culture of safety, institutions view errors as a systems issue and encourage nurses to report and discuss errors to improve patient care.” 

By creating this culture of safety and accepting error reporting without blame, the number of patient safety incident reports has increased greatly—and so has the number of discussions and systems improvements that prevent future errors.

Changes that Prevent Errors

Viewing errors as systems or process issues—rather than individual failures—has led to a review of the entire drug administration process. The resulting systems’ changes help prevent medication errors and include: 

  • Computerized order entry 
  • Computerized medication dispensing systems 
  • Barcode identification
  • Designated drug administration preparation areas
  • Minimizing what medications can be mixed outside of the pharmacy
  • Quiet zones
  • A list of “Do Not Use” abbreviations 
  • Tall man (mixed case) lettering to spell out look-alike drug names, such as acetoHEXAMIDE and acetaZOLAMIDE 
  • Ongoing staff discussions to explore potential errors and improve safety.

A survey conducted by the American Society for Health-System Pharmacists identified additional changes that can significantly decrease medication errors. These include decreasing floor stock, using unit dose dispensing, having two pharmacists check orders before dispensing drugs, using automated syringe-filling devices in a laminar-airflow hood for parenteral nutrition and having a pharmacist approve all drug orders. And when clinical pharmacists accompany other healthcare professionals on patient rounds, communication improves and medication errors drop.

For information about preventing medication errors in your facility, check out Mosby’s online course, AACN Critical Care Pharmacology, or call 1-866-416-6697.


Consumers Union. To Err Is Human: To Delay Is Deadly. Austin, TX: Consumers Union, 2009.

Institute for Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Name Sets with Recommended Tall Man Letters. Horsham, PA: Institute for Safe Medication Practices, 2008.

The Joint Commission. Facts About the National Patient Safety Goals. Oakbrook Terrace, IL: The Joint Commission, 2009.

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