general, the health care system should enable the flow of all information needed to choose medications that optimize health to the extent possible in accordance with the preferences of the patient. In addition, all health care stakeholders should attempt to produce information on and inform patients and providers about the balance between effectiveness and safety, rather than addressing either in isolation. Effectiveness (tangible benefits— those that can be felt by the patient—in the actual setting in which the medication is used) rather than efficacy (benefit based on ideal circumstances of use) is the appropriate measure for the purpose of informing patients and providers. Further, all stakeholders should strive to produce a system in which the transactions that ensue following a decision about using a medication at a particular dose and time are free of errors.


Part I of this report addresses the causes, incidence, and costs of medication errors. By way of background, it begins with a case study illustrating how medication errors can arise through a combination of organizational and individual failures. Chapter 2 provides an overview of the system for drug development, regulation, distribution, and use, identifying the many points at which errors can occur. Chapter 3 summarizes the peer-reviewed literature on the incidence and costs of medication errors.

Part II of the report outlines the steps needed to establish a patient-centered, integrated medication-use system. It provides action agendas for achieving both short- and long-term improvements in medication safety for patients/consumers to support provider–consumer partnerships (Chapter 4), for health care organizations (Chapter 5), and for the industry that provides medications and medication-related products and services (Chapter 6). In Chapter 7, the committee outlines an applied research agenda designed to foster safe medication use. Finally, Chapter 8 proposes action agendas for those who set the environment in which care is delivered (for example, legislators, payers, and regulators). Appendix B provides a glossary and acronym list for the report, while Appendices C and D present detailed discussion of medication incidence rates and prevention strategies, respectively.


ACGME (Accreditation Council for Graduate Medical Education). 2003. For Insertion into the Common Program Requirements for All Core and Subspecialty Programs by July 1, 2003: V.F. Resident Duty Hours and the Working Environment. [Online]. Available: [accessed May 26, 2005].

AHRQ (Agency for Healthcare Research and Quality). 2005. Advances in Patient Safety: From Research to Implementation. Vols. 1–4. Rockville, MD: AHRQ.

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