By Eric Andrew Kristof, RN, CAHIMS | Healthcare IT Professional | HIMSS Arkansas Chapter Member
About This Series: The HIMSS Word of the Day is a running blog series drawing from the HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025) — the authoritative reference for healthcare IT professionals and the primary study resource for CAHIMS and CPHIMS certification. Each post paraphrases the term in plain language, grounds it in real-world healthcare IT context, and adds a bedside nursing perspective you won’t find in a textbook.
📖 The Term: Medication Error
Source: HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025)
🔍 Plain-Language Definition
A medication error is a preventable mistake anywhere in the process of prescribing, preparing, giving, or monitoring a medication that could lead to the wrong use of a drug or to harm.
The HIMSS Dictionary’s definition closely follows the one used by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). It treats a medication error as any avoidable event that may result in improper medication use or injury while the drug is under the control of a clinician, the patient, or a consumer. The Dictionary also lists the many places such events can originate, including clinical practice, products, procedures, and systems, and steps such as prescribing, communicating orders, labeling, packaging, naming, compounding, dispensing, distribution, administration, patient education, monitoring, and use.
Two ideas in that definition matter most. First, the error is preventable. Second, harm is not required. An error that is caught before reaching the patient still counts, and studying those near misses is one of the best ways to prevent future harm.
NCC MERP’s index sorts errors by outcome:
| Category Group | NCC MERP Categories | Meaning |
|---|---|---|
| No Error | A | Circumstances or events with the capacity to cause an error |
| Error, No Harm | B, C, D | An error occurred; it did not reach the patient (B), reached the patient without harm (C), or required monitoring to confirm no harm (D) |
| Error, Harm | E, F, G, H | The error caused temporary harm needing intervention or hospitalization, permanent harm, or required intervention to sustain life |
| Error, Death | I | The error may have contributed to or resulted in the patient’s death |
⚠️ Exam Alert: A medication error is a preventable process failure, with or without harm. An adverse drug event (ADE) is harm from a medication, which may or may not involve an error. An adverse drug reaction is harm from a drug used appropriately, so it is not an error. A near miss or potential ADE is an error that did not reach the patient or did not cause harm. Expect a scenario question that asks which term applies.
🌐 Why It Matters: Real-World Healthcare IT Context
Medication safety was a central theme of the Institute of Medicine’s 1999 report To Err Is Human, and it remains one of the main reasons hospitals invest in clinical information systems.
A landmark 1995 study in JAMA by David Bates and colleagues found 6.5 adverse drug events per 100 nonobstetric admissions across 11 medical and surgical units, and judged 28% of them preventable. Of the errors behind preventable events, 56% occurred at ordering and 34% at administration. Just as important, 48% of ordering errors were intercepted before reaching the patient, while none of the administration errors were.
That pattern explains the technology strategy that followed. Computerized provider order entry and clinical decision support target the ordering stage with legible orders, dose checking, and allergy and interaction alerts. Pharmacist verification adds a second review. At administration, bar code medication administration confirms the right patient, drug, dose, route, and time, and smart infusion pumps with drug libraries limit programming errors. The electronic medication administration record ties these steps together.
Technology can also create new errors. Poorly designed order screens, confusing drop-down lists, and excessive alerts contribute to wrong selections and alert fatigue. Interfaces between pumps, pharmacy systems, and the EHR can introduce mismatches if they are not tested carefully.
Common sources of medication errors:
- Look-alike and sound-alike drug names and packaging
- Wrong-patient orders and wrong-patient administration
- Dose calculation errors, especially weight-based pediatric doses
- Interruptions during medication preparation and administration
- Incomplete medication reconciliation at care transitions
- Workarounds that bypass scanning or verification steps
Layers of defense:
- CPOE with dose range, allergy, and interaction checking
- Pharmacist review of new orders
- Barcode scanning of patient and medication at the bedside
- Smart pumps with drug libraries and, where available, pump-EHR integration
- Independent double checks for selected high-alert medications
- Error reporting systems backed by a just culture
🏥 The Nurse’s Perspective: Clinical, Bedside, & Workflow
Nurses administer most inpatient medications, which places them at the stage where an error is least likely to be caught by anyone else.
At the Bedside
Each administration is a series of checks: confirm the patient, the order, the drug, the dose, the route, the time, and the reason, then document. Barcode scanning supports those checks but does not replace clinical judgment. A nurse who notices that a dose looks unusually large, that a patient’s blood pressure is too low for the scheduled antihypertensive, or that a new allergy has not been documented can stop an error that every system upstream missed.
High-alert medications, such as insulin, anticoagulants, opioids, and concentrated electrolytes, call for extra attention. Organizations often require independent double checks or pump programming verification for these drugs.
In Clinical Workflow
Interruptions are a well-known risk during medication preparation. Some units use quiet zones or visual signals to discourage interruptions during medication passes.
Reporting matters as much as prevention. Near misses and errors that cause no harm reveal weak points in the process. In a just culture, nurses can report those events without fear of automatic blame, and leaders can separate system problems from at-risk behavior and reckless behavior. Without reporting, the same failure tends to repeat on the next shift.
In EHR Implementation (Go-Live Perspective)
During an Epic Go-Live, the medication process is one of the highest-risk areas. Nurses are learning a new eMAR, new scanning workflows, and new ways to see pending and discontinued orders at the same time. At-the-elbow support analysts often help with scanner setup, scan override reasons, and finding medications that are due, overdue, or held.
Medication conversion deserves careful attention. Active orders moved from the old system must be reviewed and reconciled, and early tracking of scanning compliance and override rates helps teams spot workflow problems before they become habits.
🎓 CAHIMS / CPHIMS & HIMSS Perspective
CAHIMS Exam Domain Mapping
Medication errors are among the most frequently tested patient safety topics:
| CAHIMS Domain | How Medication Errors Appear |
|---|---|
| Healthcare & Technology Environments | To Err Is Human; patient safety organizations; NCC MERP and ISMP; FDA reporting |
| Clinical Informatics | The medication-use process; CPOE; decision support; BCMA; eMAR; alert design |
| Healthcare Information & Systems Management | Drug databases; pharmacy, pump, and EHR interfaces; scanning hardware; downtime procedures |
| Management & Leadership | Just culture; error reporting systems; safety metrics such as scanning compliance; root cause analysis |
Key Terms to Know Alongside Medication Error
- Adverse Drug Event (ADE) — an injury resulting from medication use, whether or not an error occurred
- Near Miss — an error that was caught before it reached the patient
- NCC MERP Index — a nine-category scale (A through I) for classifying medication errors by outcome
- High-Alert Medication — a drug that carries a heightened risk of significant harm when used in error
- Just Culture — a safety approach that balances accountability with learning from system failures
- Medication Reconciliation — comparing medication lists across care transitions to resolve discrepancies
HIMSS Organizational Position
HIMSS treats medication safety as a core use case for clinical informatics, connecting it to its work on EHR optimization, clinical decision support, and nursing practice. Its Nursing Informatics Community focuses on technology that supports safe medication administration. Members can find related education and research through the HIMSS Resource Center.
🔗 Explore Further: External References
- NCC MERP — About Medication Errors https://www.nccmerp.org/about-medication-errors
- NCC MERP — Index for Categorizing Medication Errors https://www.nccmerp.org/types-medication-errors
- FDA — Medication Errors Related to CDER-Regulated Drug Products https://www.fda.gov/drugs/drug-safety-and-availability/medication-errors-related-cder-regulated-drug-products
- AHRQ PSNet — Medication Errors and Adverse Drug Events https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
- Bates et al. (1995), JAMA — Incidence of Adverse Drug Events and Potential Adverse Drug Events https://pubmed.ncbi.nlm.nih.gov/7791255/
- Institute of Medicine (1999) — To Err Is Human: Building a Safer Health System https://www.nationalacademies.org/projects/HMD-HCS-18-P-114/publication/9728
Term source: HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025). All definitions in this series are paraphrased for editorial purposes. Readers are encouraged to consult the primary source for exact language.
Eric Andrew Kristof, RN, CAHIMS is a Healthcare IT professional and HIMSS Arkansas Chapter member based in Hot Springs Village, AR, with hands-on Epic Go-Live experience and a diverse healthcare and IT background. He writes at kristof.org at the intersection of clinical care and healthcare technology.
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