[An integrated project to prevent and minimize medication errors. The Istituti Ortopedici Rizzoli of Bologna's experience].

Medication errors are a well-known problem in healthcare organizations. Several studies have shown that medication errors and adverse drug events (ADEs) are the biggest causes of adverse events in hospitals. This work will present the Istituti Ortopedici Rizzoli of Bologna's project, which has an systemic and integrated approach to prevent and minimize medication errors. The project performed this activities: a cognitive survey to learn the nurse staff's knowledge and perception of risks level; educational activities to sensitize nurse staff; a detailed retrospective study, based on the analysis of clinical records, to determine the rate of medication errors in the prescription and transcription phases; the introduction of a unified tool for medication, which eliminates the transcription phase, enable the medication prescription and the administered drug to be recorded.