delivered, including legislators, regulators, accreditors, payers, and patient safety organizations.3

Recommendation 7: Oversight and regulatory organizations and payers should use legislation, regulation, accreditation, and payment mechanisms and the media to motivate the adoption of practices and technologies that can reduce medication errors, as well as to ensure that professionals have the competencies required to deliver medications safely.

  • Payers and purchasers should continue to motivate improvement in the medication-use process through explicit financial incentives.

  • CMS should evaluate a variety of strategies for delivering medication therapy management.

  • Regulators, accreditors, and legislators should set minimum functionality standards for error prevention technologies.

  • States should enact legislation consistent with and complementary to the Medicare Modernization Act’s electronic prescribing provisions and remove existing barriers to such prescribing.

  • All state boards of pharmacy should undertake quality improvement initiatives related to community pharmacy practice.

  • Medication error reporting should be promoted more aggressively by all stakeholders (with a single national taxonomy used for data storage and analysis).

  • Accreditation bodies responsible for the oversight of professional education should require more training in improving medication management practices and clinical pharmacology.


The American people expect safe medication care. In this report, the committee proposes an ambitious agenda for making the use of medications safer. This agenda requires that all stakeholders—patients, care providers, payers, industry, and government, working together—commit to preventing medication errors. Given that a large proportion of injurious drug events are preventable, this proposed agenda should deliver early and measurable benefits.


Patient safety organizations are regulated through the Patient Safety and Quality Improvement Act of 2005 (P.L. 109-41). Broadly, they are organizations separate from health care providers that collect, manage, and analyze patient safety data, and advocate safety improvements on the basis of analysis of the patient safety data they receive.

The National Academies of Sciences, Engineering, and Medicine
500 Fifth St. N.W. | Washington, D.C. 20001

Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement