Medication errors remain a leading cause of preventable harm in healthcare settings, contributing significantly to patient morbidity, mortality and increased healthcare costs. With global initiatives such as the WHO’s ‘Medication without Harm’ and the Global Patient Safety Action Plan 2021–2030, attention has increasingly turned to strategies for mitigating these errors.
In Europe, efforts led by the European Association of Hospital Pharmacists (EAHP) have underscored the value of a systems-based approach. Through the work of a Special Interest Group (SIG), comprised of pharmacists and safety experts from ten countries, critical incident reports were analysed to identify root causes of medication errors and propose actionable interventions. Their findings highlight the systemic nature of these errors and advocate for policy and practice reforms at multiple levels.
Understanding Root Causes: System-Level and Individual Failures
The SIG classified 89 medication-related incidents using Reason’s Swiss Cheese Model, which distinguishes between active (individual) and latent (system-level) failures. Thirty of these incidents stemmed from system-level issues. Organisational and governance deficiencies included unclear responsibilities and delegation to unqualified staff. Human resource gaps, such as understaffing and the employment of insufficiently trained personnel, further compromised safe medication handling. Technical shortcomings—ranging from outdated equipment to inadequate digital infrastructure—were particularly prevalent, accounting for more than half of the system-level errors.
The majority of the remaining incidents (59 cases) were classified as active individual errors. Among these, most were mistakes—errors in decision-making or judgement—rather than slips or lapses. Errors occurred frequently during prescribing, dose calculation and administration, often exacerbated by stress, interruptions and inadequate knowledge. These findings reaffirm the interconnectedness of human error and organisational conditions, highlighting the importance of robust support structures, comprehensive training and efficient resource management to prevent harm.
Interventions for Safer Medication Practices
Drawing from both incident analysis and a broad literature review, the SIG identified a spectrum of interventions to address the root causes of medication errors. Several of these focused on technological solutions. The combination of Computerised Prescriber Order Entry (CPOE) with Clinical Decision Support (CDS) systems was among the most frequently studied and demonstrated a significant reduction in errors and adverse drug events. Similarly, smart pumps and closed-loop medication systems improved the safety of intravenous drug administration, although their efficacy was dependent on correct configuration and adherence to protocols.
Automation and digital tools such as electronic dispensing cabinets, barcode scanning and standardised electronic workflows offer further means to enhance accuracy and accountability. However, these technologies must be supported by sound governance and operational policies to function effectively. The integration of pharmacist-led interventions also emerged as a critical factor. Multidisciplinary medication reviews, reconciliation at care transitions and active pharmacist participation in clinical teams contributed to a measurable reduction in preventable harm.
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Education was another central theme. Simulation-based training and prescriber education were found to significantly lower prescribing errors. Efforts to engage patients in their own medication management—through reconciliation and access to health records—also showed promise, although their implementation remains limited. A multi-pronged approach combining human-centred design, policy reinforcement and technological innovation is essential to advance medication safety in healthcare settings.
Building the Foundations for a Safety Culture
For systemic change to occur, the study underlines the necessity of embedding patient safety into the institutional culture. This begins with governance reforms that clarify accountability, empower qualified personnel—particularly pharmacists—with decision-making authority and promote a non-punitive approach to incident reporting. Institutional policies should align with Good Manufacturing Practices and incorporate clear procedures for corrective and preventive actions. Tools such as Failure Mode and Effects Analysis can help proactively identify risks before harm occurs.
Addressing human resource challenges requires more than just recruitment. Institutions must ensure that staffing levels are adequate and that personnel are appropriately qualified and supported. Task-shifting to pharmacy technicians and clinical pharmacists, limiting workloads and removing unqualified staff from high-risk roles are all necessary steps to reduce the strain on frontline workers.
Finally, technical infrastructure must be modernised. Investments in decision support systems, interoperable records and automation tools will only be effective if their implementation is coupled with training and strategic oversight. System designs should prioritise user-friendliness and be resistant to errors under real-world conditions, such as interruptions and time pressure. Encouragingly, the study demonstrates that where these conditions are met, the occurrence and severity of medication errors can be significantly reduced.
The European SIG’s comprehensive analysis reveals that medication errors result from a combination of latent system vulnerabilities and active human failings. To move beyond reactive and blame-focused responses, healthcare systems must adopt a systemic lens—one that integrates technology, education, resource planning and culture change. The recommended measures span institutional governance, human resources and technical operations, reflecting the multifaceted nature of the challenge. By addressing the structural root causes and reinforcing safety at every level, hospitals across Europe can make meaningful progress in safeguarding patients from preventable harm.
Source: European Journal of Hospital Pharmacy
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