Tackling medication errors: how a systems approach improves patient safety
Year: 2025
Type: article
Abstract: OBJECTIVES: Medication errors are a leading source of preventable harm in healthcare, affecting approximately 1 in 30 patients, with a substantial proportion resulting in severe outcomes. In response, the European Association of Hospital Pharmacists convened a Special Interest Group (SIG) to propose comprehensive and sustainable strategies for reducing these errors across Europe, employing a systems approach. METHODS: 89 anonymised medication error reports, and empirical data from the SIG members' daily practice, were analysed to identify root causes, classified into system-level and individual errors. Expert subgroups then linked root causes to targeted preventive measures. A literature review was conducted, searching PubMed and Embase databases, to assess existing standards and identify gaps in medication safety practices, which informed the analysis. RESULTS: Analysis revealed that governance deficiencies and inconsistent implementation of existing legal standards contribute significantly to medication errors. System-level issues, including inadequate oversight, understaffing and insufficient technical infrastructures, along with individual errors from cognitive lapses, were prevalent. The literature review supported these findings and highlighted the variability in medication safety practices across systems, underscoring the importance of strategic improvements in healthcare policies. CONCLUSIONS: Findings highlight the critical need for robust governance, comprehensive policy frameworks and enhanced safety cultures to prevent medication errors. Automation and improved human-machine interfaces are recommended to mitigate active failures and enhance system reliability. This systems-thinking approach, supported by strengthening legislation and better resource allocation, is essential for reducing medication errors and improving patient safety.
Authors: Sonja Guntschnig, Renata Barbosa, Helena Jenzer, Matthew Greening, Jennifer Hayde, Helen Heery, Maria Cristina Iglesias Serrano, Kristína Lajtmanová, Elisabetta Rossin, Slagjana Tentova-Peceva, Stephanie Kohl, Alma Mulac
Institutions: University of Ulster, Hospital da Senhora da Oliveira Guimarães, Bern University of Applied Sciences, NHS England, Tallaght University Hospital, Portiuncula Hospital, Hospital Universitario Son Espases, National Institute of Cardiovascular Diseases, Azienda Socio Sanitaria Territoriale della Valle Olona, Oslo University Hospital, University of Oslo
Language: English
Subfield: Emergency Medical Services
Field: Health Professions
Domain: Health Sciences
Open Access status: hybrid
Funder: Baxter International
Award: G3084055986
OpenAlex ID: W4409798111