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Medication Safety Management

When an Ounce of Prevention is Worth More Than a Pound of Cure

By Hilary Anderson, Shannon Mommsen, Sara Khan, Abir O. Kanaan, Karyn Sullivan, Paul Belliveau

Medication Safety Management



Medication errors are preventable events that can negatively impact patient outcomes and result in unnecessary admissions, prolonged hospital stays, and death. Health care professionals (HCPs) often analyze these events to identify the cause of the error, determine actual or potential impact on patients, and work collaboratively to implement corrective action plans to prevent similar recurrences. This case study follows a patient through a series of hospital admissions to highlight various aspects of medication error discovery, investigation, and analysis. As they work through the case study, students categorize medication errors, identify factors leading to medication errors, explore a root cause analysis of the events, and discuss feasible solutions to prevent future errors. Additionally, students participate in discussions about “just culture” and medication error reporting, and why including reports of events that did not cause patient harm is important in improving the medication system. This case study is designed for HCPs, students in designated HCP training programs, and public health stewards.


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  • Define medication error and adverse drug reaction.
  • Explain why some medications have a high-alert categorization.
  • List examples of high-alert medications.
  • Identify patient and care-giver high-alert medication counseling points.
  • Identify contributing factors and solutions to preventing a medication error.
  • Identify adverse drug event types.
  • Categorize a medication error event based on the NCC MERP index.
  • Describe steps of a root cause analysis for a medication event.
  • Describe benefits of having a “Just Culture.”
  • Describe the Swiss cheese model in the context of preventing medication events.
  • Identify near-miss events and opportunities to improve systems.
  • Describe the importance of near-miss event reporting.


Medication safety; medication error; high alert medication; adverse drug reaction; root cause analysis; just culture; safety culture; system errors; Swiss cheese model; near miss; great catch


Subject Headings

Interdisciplinary Sciences
Medicine (General)
Pharmacy / Pharmacology


Graduate, Professional (degree program), Clinical education, Continuing education












Analysis/Issues, Discussion



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