Reports spotlight medication errors: make changes before tragedy strikes.

Three organizations recently published reports on medication errors--the Institute for Healthcare Improvement, the Institute of Medicine, and the Joint Commission on Accreditation of Healthcare Organizations. The ED is at higher risk for medication errors than other areas of the hospital because of extreme time pressure, high patient volumes, verbal orders, and multiple staff caring for patients. Medication errors often are caused by unclear labeling, lack of a check system for medication dosages, and similar drugs kept in close proximity to each other. Recommended strategies include a check system in which one nurse prepares a dose and another nurse reviews it, and avoiding look-alike and sound-alike medications.