Medication Errors Once Again Listed in the Top Ten: A Persistent Threat to Patient Safety

Medication Errors Once Again Listed in the Top Ten: A Persistent Threat to Patient Safety

Every year, the Joint Commission—the organization responsible for accrediting and certifying healthcare institutions across the United States—publishes its list of the most common Sentinel Events, or serious, preventable adverse outcomes that result in death, permanent harm, or severe temporary harm to patients. Once again, medication errors have appeared among the top ten Sentinel Events for 2024. Despite decades of awareness, training, and system improvements, these errors remain one of the most persistent—and preventable—causes of patient harm in American healthcare.

According to the Joint Commission and research from national health safety agencies, between 7,000 and 9,000 people die each year from medication errors in the United States. These are not obscure mistakes. They occur in hospitals, nursing homes, outpatient facilities, and even pharmacies—anywhere medication is prescribed, dispensed, or administered.

Medication errors can take many forms:

• A nurse administering the wrong dose.
• A physician prescribing a drug contraindicated for a patient’s allergies.
• A pharmacist mislabeling a medication.
• A communication breakdown during a patient handoff.

Each of these scenarios has one tragic thing in common: they are preventable.

A “Sentinel Event,” by definition, signals the need for immediate investigation and response. It is not merely a statistic—it represents a real human being whose life was permanently changed, and a system failure that should have been caught before it ever reached the bedside.

The Joint Commission’s data and accompanying root cause analyses have identified several recurring factors behind medication-related Sentinel Events. Among them are:

• Human factors, including fatigue, distraction, and cognitive overload.
• Poor communication between providers, especially during transitions of care.
• Inadequate labeling and storage of medications.
• Look-alike/sound-alike drug names, which can cause confusion even for experienced staff.
• Lack of standardized processes, particularly in smaller facilities or busy hospital units.

Despite the availability of technology like electronic prescribing systems and barcode scanning, medication safety still depends heavily on consistent human diligence. Automation can reduce, but not eliminate, the risk of human error.

Preventing Medication Errors: Common Sense and Consistency

Patient safety experts have long emphasized that most medication errors can be prevented through simple, standardized safety practices. The Joint Commission’s 2024 report reinforces this message—patient safety is not “rocket science.” It is about doing the basics right, every time.

Here are several key strategies healthcare providers are urged to follow:

1. Double-check computer-generated orders.
    Even sophisticated electronic medical record systems can produce errors. Prescribers must always review and confirm the accuracy of a computer-generated medication order before submitting it.
2. Avoid abbreviations.
    Shortened medication names or Latin abbreviations (like “qd” for daily or “U” for units) can easily be misread. The Joint Commission maintains a “Do Not Use” list of abbreviations for this reason.
3. Never use a trailing zero.
    Writing “5.0 mg” may look precise but can easily be misread as “50 mg.” The correct notation is “5 mg.” Conversely, always use a leading zero for decimal doses less than one (e.g., “0.5 mg” instead of “.5 mg”).
4. Limit verbal orders.
    Whenever possible, orders should be written or entered electronically. If a verbal order is necessary, the receiving nurse should repeat it back verbatim to confirm accuracy.
5. Collaborate with pharmacists.
    Pharmacists are an underutilized safety net. Their specialized knowledge of drug interactions, contraindications, and proper dosing can prevent serious harm.
6. Remove high-risk medications from common areas.
    Certain drugs—such as concentrated electrolytes, insulin, or heparin—pose higher risks if administered incorrectly. These should be stored in secure, limited-access locations.
7. Label everything.
    Every syringe, medication cup, or IV bag should be clearly labeled immediately after preparation. Many errors occur simply because a container was left unmarked, forcing a provider to guess.
8. Use single-unit dose packaging.
    Pre-packaged single-dose medications reduce the risk of incorrect preparation and cross-contamination.
9. Improve communication during handoffs.
    Hospitals should adopt standardized “hand-off” tools and checklists to ensure all relevant patient information—including medications—is clearly communicated when care shifts between providers.
10. Practice the “Five Rights.”
     Before administering any medication, nurses must verify the Right Drug, Right Dose, Right Route, Right Time, and Right Patient. It’s one of the simplest and most effective safety checks in medicine.

Behind every medication error is a cascade of small oversights—a moment of inattention, a missed double-check, a communication breakdown. Many healthcare professionals report that pressure to move quickly, understaffing, and constant multitasking make it difficult to follow all safety protocols perfectly.

But patient safety cannot be sacrificed for speed. The Joint Commission emphasizes that discipline, communication, and culture are the backbone of error prevention. Creating a culture where staff feel empowered to question, verify, and slow down when something seems off is essential.

For patients and families affected by medication errors, the impact can be devastating. The law recognizes this. Medication mistakes often fall under the category of medical malpractice—a healthcare provider’s failure to meet the accepted standard of care, resulting in injury or death.

Common forms of negligence in medication error cases include:

• Prescribing or administering the wrong medication or dose.
• Failing to monitor a patient for adverse reactions.
• Poor communication between physicians, nurses, or pharmacists.
• Not adjusting medications for a patient’s weight, allergies, or preexisting conditions.

A successful malpractice claim generally requires proving four elements: duty, breach, causation, and damages. In other words, the provider owed a duty to the patient, failed to meet that duty, that failure caused harm, and the harm resulted in measurable damages.

Attorneys handling medication error cases often work with medical experts to analyze treatment records, pharmacy logs, and hospital policies to determine where the system broke down—and who bears responsibility.

While much of the responsibility lies with healthcare providers and institutions, patients can play an important role in preventing medication errors as well. The Joint Commission encourages patients to:

• Keep an up-to-date list of all medications, including over-the-counter drugs and supplements.
• Ask questions if something looks different from usual.
• Verify the name and purpose of every medication before taking it.
• Report any unexpected side effects immediately.

Being an informed and engaged patient can add an additional layer of protection against preventable harm.

The fact that medication errors remain among the top ten Sentinel Events for 2024 is both discouraging and instructive. It underscores how deeply ingrained systemic issues are within modern healthcare—and how critical vigilance, training, and accountability remain.

The path forward requires commitment at every level of the healthcare system: from executives who must prioritize patient safety resources, to frontline clinicians who must resist shortcuts under pressure. As the Joint Commission reminds us, safety is built not through heroics but through habits—simple, consistent actions that protect lives.

Medication safety is one of the clearest measures of healthcare quality. Every medication order, every syringe label, every patient handoff represents an opportunity to prevent harm—or to cause it.

As legal advocates for victims of medical malpractice, we are reminded daily that these “sentinel” mistakes are not mere statistics—they are personal tragedies that ripple through families and communities. Accountability matters not just for justice, but for prevention.

When healthcare providers take the time to follow common-sense procedures, collaborate with colleagues, and put patient safety first, lives are saved. The solutions are known. The challenge is consistency. And in healthcare, consistency saves lives.