Maryland Patient Safety Center

Medication Safety

Medication errors are among the most common incidents leading to adverse events in patient care. As an estimate, one medication error occurs per hospitalized patient daily, and medication errors cost an extraordinary sum of money each year. In the United States alone, 7,000 to 9,000 people die annually due to medication error, and hundreds of thousands more experience, but often do not report, an adverse reaction or other medication-related complication.

Join MPSC throughout the year for virtual webinars, patient safety tools courses, confidential and protected roundtable discussions for shared and experiential learning, and safety reviews focused on high priority adverse events for medication safety champions.

Medication Safety  Series

This series of easy-to-consume virtual webinars will highlight emerging patient safety trends and issues of critical need in the Emergency Department.  The webinars will identify innovative strategies and implementation techniques to support ED teams in meeting their quality and safety goals and harm reduction.

Safety Series webinars are held from 12:00 – 1:00 pm EST.

Safe Tables

Safe Tables are a shared learning forum for peers to exchange patient safety experiences, discuss best practices, network and learn from each other in an open, uninhibited and legally protected environment.

Safe Tables are open to MPSC members only and are held in-person from 1:00 – 3:00pm EST.

Patient Safety Tools

Many healthcare professionals, particularly quality and safety leaders, use a variety of patient safety tools and techniques daily to ensure the delivery of highly-reliable care; but these tools also offer implementable, effective, and practical applications for front-line healthcare workers to improve patient safety systems and processes.

Patient Safety Tools courses are held virtually from 12:00 – 2:00 pm EST.

Patient Education

The Opioid Epidemic: What you need to know

A complimentary community outreach initiative to support Opioid abuse awareness and prevention


This in-person conference is an invitation-only event for identified medication safety champions at MPSC member organizations. Aimed at ensuring pharmacists and other medication safety leaders have the tools needed to craft the vision and direction for effective medication safety within their organization, this conference will identify opportunities to improve the medication use system, understand how technology can support (or hinder) medication safety, and lead implementation strategies.

For more information and a detailed agenda please visit: [coming soon…]

This one hour webinar will teach participants how to utilize various data collection methods to identify medication-related risk.  Attendees will learn how to collect, review, and analyze data regarding their organization’s medication-use process, medication errors, adverse drug reactions, and drive continuous quality-improvement by developing high-leverage error-reduction strategies. 

This two hour webinar is designed to develop a participant’s understanding of how to review and analyze the organization’s medication-use process, medication errors, adverse drug reactions, and continuous quality-improvement data. Attendees will learn to use appropriate data analysis techniques to identify needed improvements execute the necessary error-reduction strategies. 

In a protected Safe Table environment, those involved in medication safety and/or any part of the medication use process (e.g. nurses and other providers) will discuss how relying on healthcare practitioners to follow the five rights is a low-leverage strategy– one that relies solely on the performance of an inherently fallible human being at the sharp end of the medication-use process. The participants will discuss what is needed from organizational leaders, manufacturers and supplies, who are responsible for the design, implementation, and maintenance of reliable systems to support safe medication use for all practitioners. 

Smart pumps are a necessary component of a comprehensive safe medication system. This one hour webinar will focus on infusion pump dose errors as a significant source of medication errors, including incorrect medication orders, calculation errors, or misprogramming that can result in significant under- or overdelivery of a drug, electrolyte, or other fluid. Attendees will also review the need for interfacing with other systems such as the electronic medical record, computerized prescriber order entry, bar coded medication administration systems, and pharmacy information systems in order to achieve greater levels of medication safety.

This virtual half-day conference is open to all healthcare professionals with an interest in medication safety. The expert presenters will address priority areas in medication safety, highlighting innovative ways to improve workflows that reduce medication errors and describe ways to optimize the use of your technology, including computerized clinical decision support, to prevent medication errors and adverse drug events.

For more information and a detailed agenda please visit MPSC’s Annual Medication Safety Conference page.

Human Factors, as a safety science, provides a framework for understanding medication safety failures and suggests that errors often are caused by poorly designed systems.  Human Factors also offers insights on improving medication safety in time pressured, information intense, mentally challenging, interruption-laden, life-or-death environments. This two hour webinar will help participants have the tools to better explore not “why did the person make the mistake,” but rather “what caused the mistake to occur?” The Human Factors process also helps medication safety leaders take a deeper drive into root cause analyses. 

The overriding of safety controls in automated dispensing cabinets (ADC) has been identified as a top technology-related medication safety issue. ADC overrides bypass the safety features of order entry and verification which increase the risk of an error occurring and potential patient harm.  During this one hour webinar, medication safety leaders will discuss review of overriding trends and available medications on override. The webinar will discuss investigation of the risk of error and identification of interventions to proactively limit patient risk.  

This one hour webinar is designed for those involved with medication safety and those championing safety the emergency department. The presentation will focus on medication errors in the ED that occur during the ordering/prescribing and administration stages of the medication-use process, the most common medication errors in the ED, and the medications most frequently involved in ED careIn addition, the webinar will review high-impact, achievable recommendations to improve safe medication delivery in the ED environment. 

Failure mode and effects analysis (FMEA) is a prospective, team based, structured process used to identify system failures of high risk processes before they occur. The medication use system is a risky process that should be analyzed for its inherent risks using FMEA. This two hour webinar will provide the tools to apply FMEA principles to medication safety by identifying possible failure modes, their effects, and causes in the medication use process. 

This one hour webinar will discuss  the importance of reviewing patient falls from a medication safety perspective in order to help reduce overall fall rates in the hospital.  Certain medications, such as psychoactive medications, antihistamines, muscle relaxants, blood pressure medications, and anticholinergics may increase fall risk. Participants will explore medication-related risk factors and strategies to prevent patient falls in the at risk populations. 

This one hour webinar is designed for healthcare professionals who champion medication safety and those who work in labor and delivery. Participants will learn about medication errors in labor and delivery, including high-alert medications, the most common medication errors associated with labor, and the medications most frequently involved in labor and delivery, such as oxytocin and magnesium sulfate. In addition, the webinar will review high-impact, achievable recommendations to improve safe medication delivery in the labor and delivery environment, from pregnant and post partum people. 

In a protected Safe Table environment, those involved in medication safety and those involved in Labor and Delivery will discuss errors in intravenous (IV) oxytocin administration, which can cause excessive stimulation of the uterus, potentially resulting in fetal distress, an emergency cesarean section, uterine rupture as well as maternal, fetal or neonatal death. The Safe Table will also focus on other prescribing, packaging, lookalike/sound alike medications, and preparation errors; along with high-impact, achievable recommendations for harm reduction in Labor and Delivery. 

This one hour webinar will explore the ways in which medication safety champions might gain a better understanding of how disparities in medication safety and medication-related outcomes exist for racial/ethnic minorities and other vulnerable populations. The webinar will focus on high-impact, achievable recommendations to improve health equity in medication safety in the hospital setting. 

MPSC operates a listserv for healthcare professionals with an interest in medication safety. The listserv offers a network for shared and experiential learning and is used by MPSC to share upcoming events and information specific to safety in this specialty. MPSC members may use the listserv to pose questions to the group in order to garner feedback, solutions, and gain consensus on topics related to quality of delivery, dispensing, and safe medication use. Please contact to be enrolled.