PSO Lessons Learned: Medication Errors

September 10, 2015    |   By: Calevir

Annually, the majority of events submitted to the Center for Patient Safety’s PSO result in no harm to the patient, however, there is a steady increase in events reported to the PSO which supports continued learning. With nearly 35,000 events from healthcare organizations, medication events continue to be the highest reported event type, followed by falls.

Accurate medication reconciliation is a challenge. There are near misses and patient events reported to the Center’s database related to errors which occurred because the reconciliation process was either skipped or not done properly. In one case, a patient received another patient’s medications in error because they had been entered in the wrong medical record. Due to the patient’s underlying renal failure, the incorrect medications exacerbated the condition, resulting in death.


Streamline the reconciliation process as much as possible, but ensure that staff understand the importance of completing it accurately for every patient and  follow the “5 Rs”:

  • Right Medication
  • Right Patient
  • Right Time
  • Right Dosage
  • Right Route of Administration


PSO adverse event reporting cannot be used for comparison of individual organizations. The purpose of PSO adverse event reporting is to learn what events occur and why, and to use that information to prevent future occurrence and patient harm. The value is in the quantity, quality, and details. The more reports obtained by the PSO containing detailed information about errors, near misses, and unsafe conditions, the greater potential for learning, sharing, and proactively preventing future harm, costs, and liability exposure.

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