For patients,every day should be Medication Safety Day

A formerly active 76-year-old man was prescribed a diuretic-containing regimen for heart failure. This rendered him homebound, and he began feeling sad and anxious. His internist prescribed escitalopram, and the symptoms improved. However, when he was admitted to the hospital for diuresis, escitalopram was inadvertently omitted from his regimen. Although his fluid overload was treated successfully, he became visibly anxious, depressed, and confused. A family friend who was visiting noticed that he was no longer receiving escitalopram. This was restarted, and his mood returned to normal.

This incident of antidepressant discontinuation syndrome was an adverse drug event (ADE) that could have been prevented by medication reconciliation at the time of hospital admission. It also demonstrates the important role that patients and their caregivers can play in assuring their own medication safety.

Medications are a fixture in modern society—taken to prevent and cure diseases, and to improve or maintain health. So many people take medications routinely, and so many of them take multiple medications every day. But although they have benefits, there are also dangers that many do not understand clearly.

Medication errors occur at a higher rate than most realize. This is partly because of the numerous factors, individuals, and entities involved in the medication use process. But it is also because medications are used so commonly. It is estimated that in 2023, over 6.9 billion prescriptions were dispensed in the US, and approximately 15 billion a year worldwide.^1,2 In 2020, approximately half of the adults in the US reported taking at least one prescription medication in the past 30 days. ³

The frequency is higher for older adults. In a nationally representative sample of US adults 65 and older, in 2020, 90% of people were taking at least one prescription medicine, with a mean number of 4.3; 43% were taking five or more medications (which defines polypharmacy and increased risk), and 6.1% were taking 10 or more. ⁴ On a hospital geriatric unit in China, 43.4% of patients aged 65–70 were taking at least one potentially inappropriate medication, and among patients over 80, the figure was 58.2%. ⁵

Unsafe medication practice and medication errors are a leading cause of avoidable harm in both inpatient and ambulatory care. In a random sample of admissions to US hospitals, there was at least one adverse event in 23.6%, and 39% of these were ADEs. ⁶ A study of pediatric inpatients in Japan found 76 ADEs per 1000 patient days, 23% of which were preventable. ⁷

A population-based study of Swedish adults, including both inpatients and outpatients, found that in a 3-month period, 12% of patients experienced an ADE, approximately half of which were preventable. ⁸ A study of medication errors in the English National Health Service found that four out of 10 errors took place in ambulatory care, and that three-quarters of 66 million clinically important errors occurred outside of hospitals. ⁹ A study in outpatient settings in the US found that 5% of patients experienced an ADE over the period of one year. ¹⁰ A systematic review of medication errors in outpatient settings found errors in 23%–92% of all drugs prescribed. ¹¹

Following the landmark “Preventing Medication Errors” report from the US National Academy of Medicine, there have been worldwide efforts to reduce harm caused by medications. ¹² In 2017, the WHO launched “Medication without Harm” as the third Global Patient Safety Challenge. ¹³ Its three top priority areas were high-risk medications and situations, polypharmacy, and transitions of care. The campaign brought needed visibility to the problem and provided useful tools such as the “5 moments for Medication Safety.” ¹⁴ However, the goal of reducing severe avoidable harm related to medications by 50% within 5 years was not attained, and in 2022 WHO selected “Medication Without Harm” as the theme for World Patient Safety Day. ¹⁵ This theme was consistent with the Global Patient Safety Action Plan's strategic objective to “provide information and education to patients and families for their involvement in self-care…” ¹⁶

The risks associated with high-risk medications, polypharmacy, and transitions of care can all be mitigated by involving patients and caregivers in their own care. There are now national and international events that aim to engage these key stakeholders in medication safety. In the US, Medication Safety Week was established by the non-profit National Council on Patient Information and Education to educate both professionals and the public on reducing the risk of medication errors. ¹⁷ This year, it is observed beginning on 1 April, and centers on collaboration and patient involvement to achieve a better understanding and use of medications.

National Check Your Meds Day was established in 2017 by the non-profit Consumer Reports and takes place annually in the US on 21 October. ¹⁸ The occasion is designed to encourage patients to bring their prescription bottles to a pharmacist for a review of potential interactions or expired drugs. It serves as a reminder that patients must be more cautious about how to use medications, know what they are taking, and how to take them correctly.

International Medicines Safety Week was established in 2016 by the Uppsala Monitoring Center to encourage people to report suspected side effects of medications. ¹⁹ The event runs from 3 to 9 November to encourage patient safety stakeholders worldwide to report suspected side effects of medicine. The tenth annual #MedSafetyWeek was observed in 2025 and featured 118 countries, 133 organizations in 62 languages, with the theme “how everyone can help make medicines safer.”

Despite the appeal of these events, their impact has received little study. In this issue of the Journal, papers focus on efforts to make medication use safer.

Cole and colleagues conducted a quasi-experimental study to reduce intravenous immunoglobulin ADEs (Cole). ²⁰ At their institution, these events occurred primarily during drug administration, and the study evaluated a pharmacist-led intervention to improve programming of infusion pumps to capture dose and patient weight. The intervention resulted in more appropriate programming and fewer adverse drug reactions.

Davodi and colleagues conducted a scoping review that summarizes the evidence on patient-controlled sedation in adult medical and surgical procedures, focusing on usage, satisfaction, safety, and economic potential. ²¹ Usage was most common for dental procedures and colonoscopy. For these indications, patients experienced improved comfort, there was reduced drug consumption, and fewer severe adverse events. There was also a suggestion of lower costs compared to provider-administered sedation.

The scoping review by Dwinta and colleagues summarizes the types of medication errors in community pharmacies. ²² Similar to previous studies, the most common type of medication errors was in dispensing. However, medication errors were reported at all stages of the medication use process, including prescribing, administration, and monitoring.

The cases presented by Lally and colleagues describe renal tubular acidosis caused by the misuse of the combination of ibuprofen and codeine. ²³ Though this syndrome is uncommon, the overall risk is great due to the broad accessibility of both medications. The authors propose more stringent regulation in the dispensing of the combination of non-steroidal anti-inflammatory drugs and opioid tablets.

The editorial by Hambly noted slow progress in the adoption of human factors and ergonomics (HFE) science to improve safety in healthcare. ²⁴ Although these developments have been promising, progress has been slower in the use of parenteral drug therapy. This deficit is particularly troubling, as the intravenous route of administration can lead to direct harm.

In summary, taking medication is part of daily life for the majority of people. Patients and caregivers must contend with a complex landscape of challenges to safe medication use. Raising awareness among patients about the risks linked to medication use and the strategies they can adopt to minimize those risks are essential steps toward enhancing safety. These efforts deserve rigorous evaluation to determine their effectiveness. Further research focused on these objectives could provide guidance on how to make care safer.