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Planning for the Inevitable: Medication Errors

Although technology and automation have contributed to improvements in the area of medication error prevention, wrong-drug and wrong-dose dispensing errors continue to occur because of system failures and human factor errors. Reviewing medication errors that have happened at other practice sites and conducting RCA with action plans as medications errors occur will help pharmacists follow safe medication practices and keep patients safe. The content of this presentation will cover case studies of medication errors and review the root cause analysis (RCA) and action plan development processes, demonstrating the benefit of both as a preventative measure.

Learning Objectives

Upon completion of this activity, the participant will be able to:

  • Discuss the types of errors most likely to cause a sentinel event.
  • Review best practices aimed at reducing medication errors in your pharmacy.
  • Describe root cause analysis and when it should be conducted in your pharmacy.
  • Identify risk management strategies in the medication use process that can minimize or prevent medication errors.


Donna Horn, MS, RPh, DPh, CHC is a Senior Ethics and Compliance Officer at Fresenius Medical Care, North America (FMCNA) supporting the pharmacy and laboratory businesses. Concurrently, Donna is a Senior Associate at Gates Healthcare Associates where she advises clients on community pharmacy practice, regulatory compliance, medication safety initiatives and continuous quality improvement matters. Previously Donna directed ISMP’s patient safety activities in community/ambulatory practice for over 12 years.

Donna also provides direct student instruction at MCPHS as a preceptor in the APM lab. At the University of Florida, she teaches ‘Preventing Medication Errors’ to graduate students enrolled in the College of Pharmacy Pharmaceutical Outcomes and Policy Program. She has more than 25 years of experience in the retail/chain community pharmacy practice setting, as the Privacy Officer and Manager of Regulatory Affairs for Brooks/ Eckerd Pharmacy and as a pharmacist and Regional Pharmacy Manager for OSCO Drug. Donna received a BS in Pharmacy from MCPHS. She received a Graduate Certificate in Patient Safety and Medication Use and a master’s degree in Patient Safety and Medication Risk Management from the University of Florida College of Pharmacy Pharmaceutical Outcomes and Policy Program.

Registration Fee: Free for MCPHS alumni and full-time staff; $12.00 for all other professionals.


Release Date: December 16, 2022
Expiration Date: December 15, 2023
ACPE UAN: 0026-0000-22-019-H05-P | Knowledge-based
ACPE UAN: 0026-0000-22-019-H05-T | Knowledge-based
ACPE Topic Designator: Patient Safety
Contact Hours: 1 (0. 1 CEU)


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Massachusetts College of Pharmacy and Health Sciences is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Massachusetts College of Pharmacy and Health Sciences designates this activity for a total of 1.0 contact hour (0.1 CEU).

Requirements for Credit

To receive credit, participants must complete pre and post-assessments, view the entire presentation, and evaluate the session. Participant credit will be reported to the CPE Monitor upon conclusion. Transcripts may be printed from the CPE Monitor.

Statement of Disclosure

The policy of Massachusetts College of Pharmacy and Health Sciences is ensuring balance, independence, objectivity, and scientific rigor in all of its educational activities. Any individuals involved in planning or content creation for a continuing education activity are required to disclose financial relationships with ineligible companies that have occurred within the last 24 months. The intent of the policy is to identify and mitigate potential conflicts of interest that may affect the activity. All clinical medicine recommendations must be based on evidence accepted within the medical profession.

Donna Horn is an employee of Fresenius Medical Care, an ineligible company. The content of this presentation does not relate to the product lines or solutions produced or offered by Fresenius Medical Care.

Massachusetts College of Pharmacy and Health Sciences Continuing Education staff members hold no financial relationships with ineligible companies related to the content of this presentation.

Massachusetts College of Pharmacy and Health Sciences will identify, review, and mitigate all conflicts of interest disclosed prior to delivery of an educational activity to learners. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but provides participants with information that may be of potential importance when they are evaluating content.