Medication Safety in the Emergency Department: A Study of Serious Medication Errors Reported by 101 Hospitals From 2011 to 2020


  • Elizabeth Kukielka, PharmD, MA, RPh Patient Safety Authority
  • Rebecca Jones, MBA, RN Patient Safety Authority



medication safety, patient safety,, emergency department, medication error, epinephrine, emergency medicine pharmacist


Visual Abstract

Background: Although serious medication errors are uncommon, accounting for only 0.4% (166 of 46,568) of medication errors reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2020, their effects can be devastating for patients and their loved ones.

Methods: We queried PA-PSRS for reports of serious events classified as medication errors that occurred in the emergency department (ED) from January 1, 2011, to December 31, 2020. We performed a descriptive analysis to identify trends among patient sex, patient age, event harm score, event day of the week, and event time of day. We also manually coded and analyzed events based on the prescribed medication(s) and medication class(es), stage of the medication-use process at which the error occurred, and medication error type.

Results: We identified 250 reports of serious medication error events in PA-PSRS that occurred in the ED from 2011 to 2020. Reports more often specified that the patient was female (61.2%; 153 of 250), and patients ranged in age from 8 months to 96 years, with a median patient age of 55 years. Events were significantly more likely to occur Friday through Sunday versus Monday through Thursday (p = .0214) and in the p.m. hours versus a.m. hours, (p = .0007). The most common prescribed medications mentioned in reports were epinephrine, insulin, hydromorphone, sodium chloride, heparin, propofol, diltiazem, ketamine, and morphine. Events occurred most often at the prescribing stage of the medication-use process (42.0%; 105 of 250), and the most common medication error type was a wrong dose (42.0%; 105 of 250).

Conclusion: Potential safety strategies to consider to reduce the risk of medication errors in the ED include stocking epinephrine autoinjectors, using clinical decision support at the ordering/prescribing stage of the process, and adding an emergency medicine pharmacist as part of an interdisciplinary emergency medicine team.

Author Biographies

Elizabeth Kukielka, PharmD, MA, RPh, Patient Safety Authority

Elizabeth Kukielka is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority. Before joining the PSA, she was a promotional medical writer for numerous publications, including Pharmacy Times and The American Journal of Managed Care.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones ( is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.


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Silhouette of Nurse holding syringe with a patient on a bed with an IV hooked up.



How to Cite

Kukielka, E., & Jones, R. . (2022). Medication Safety in the Emergency Department: A Study of Serious Medication Errors Reported by 101 Hospitals From 2011 to 2020. Patient Safety, 4(1), 49–59.



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