Risk Reduction Resources

Medication Safety in the Office Practice

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One in nine malpractice cases involve medication-related errors, and half of those errors occur in an ambulatory setting (CRICO, 2016). Safe medication practices in the office setting can reduce the risks of medication errors and resulting malpractice claims.

Culture of Safety

Promoting a culture of safety through open communication is one of the most effective means of ensuring medication safety in the office practice. Staff must feel empowered to report safety concerns without fear of retribution. Medication errors should be seen as opportunities to improve processes and not a reason for disciplinary action.

Medication Reconciliation

Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient's current medications, including name, dosage, frequency, and route. Reconciliation of current medications should include over-the-counter, herbal medications, and supplements, as they can interact with some prescription medications. This process involves comparing the patient's current list of medications against the provider’s medication orders at any subsequent interface of care, e.g., admission, unit transfer, step-down care transfer, discharge to home, and after the patient-physician office encounter.

Practices should develop a consistent process performed by staff with sufficient clinical knowledge using a standardized format. Include patients and family members in the process of monitoring medications and maintaining accurate medication lists. At the end of each patient visit, print a reconciled, dated medication list and provide a copy to the patient and/or others as appropriate.

Prescribing

• Drug References: Providers should have access to the most up-to-date information on medications. Subscriptions to online references are easy to access and are updated in real time.
• Consistent Practice: Consistent prescribing processes within the office practice will reduce the possibility of medication errors.
• Electronic Prescribing: Electronic prescribing reduces risks associated with illegible writing or altered prescriptions. Prescription printers, if still in use, should be located in a secure area.
• Prescription Pads:
  • Prescription pads should be used only when e-prescribing is not available.
  • Be sure prescription pads are stored in a secure location.
  • Prohibit pre-dating or pre-signing prescriptions.
  • Providers should print rather than use cursive.
  • Write quantity and dose in text as well as numerals to reduce the possibility of prescription alterations.
  • Do not use dangerous abbreviations; Refer to the Institute for Safe Medication Practices (ISMP) list of dangerous abbreviations in the Resources section at the end of this tip.
• Accurate Patient Information:
  • Update the patient’s medical history annually.
  • Include smoking and alcohol use in history.
  • Include height and weight, measured in metric units.
  • Review current allergies.
  • Review the patient’s medical history before prescribing a new medication or renewing a prescription.
• Indication for Use: If a medication has more than one use, include indications for use on the prescription. This is especially important for handwritten prescriptions for medications with look-alike and sound-alike names.
• Patient Education: Patients should have a clear understanding of the medications they are taking, including the dose, the reason they are taking the medication, potential side effects, etc. Education is provided, and patient comprehension should be documented in the patient’s medical record. Teach-back is one method for assessing a patient’s understanding of their medication and other medical information. See the Agency for Healthcare Research and Quality resource at the end of this tip for more information on how to use teach back in your practice.
• Prescription Refills:
  • A provider should be consulted prior to renewing a prescription.
  • Before renewing a prescription, review medical history, including allergies and medication history.
  • Document prescription refills in the patient’s medical record, including medication name, strength, amount filled, number of refills, date of renewal, and the name of the person authorizing the refill.
  • Develop a written policy to guide the prescription refill process. The policy should specify when a patient must be seen in the practice before a medication is refilled. The policy should be reviewed and approved annually by practice physician leaders.
• Verbal Orders: Verbal and telephone orders are higher risk and should be avoided if possible. When verbal or telephone orders are necessary, the order should be written down and then read back to the ordering provider to ensure that the information has been recorded accurately. The read-back should be documented in the patient’s medical record.
• Medical Record Documentation: Document in the patient’s medical record the medication, the dose, and the number of refills of all prescribed medications. Place a copy of prescriptions in the patient’s medical record.
• Controlled Substances: Practices should have processes in place for safe prescribing of controlled substances. For more details on developing safe opioid prescribing processes, see Medical Mutual’s Practice Tip Opioids: Avoiding Risks When Prescribing.
• High-alert Medications: Identify high-alert medications that require additional care when being prescribed, administered, or dispensed. High-alert medications have the potential to cause serious patient harm. Refer to the Institute for Safe Medication Practices (ISMP) High-Alert Medication list in the resources section at the end of this tip.

Administration

• Secure Location: Ensure that all medications, syringes, and needles are stored in a locked, secure area and not left unattended in patient care areas.
• Medication Preparation: Injections should be drawn up in a clean area, away from potential contaminants, such as laboratory specimens and sinks. Any medication drawn but not administered immediately should be labeled with the medication, dose, date prepared, and initials of the person labeling the syringe.
• Patient Identification: Require two patient identifiers, such as name and date of birth, prior to administering any medication.
• Injection Safety:
  • Staff should use an aseptic technique when injecting medications.
  • Staff should follow safe injection practices. Educate staff on the concept of one syringe, one needle, one time, and the difference between single-dose and multi-dose vials. The Centers for Disease Control’s One and Only Campaign (see references for link) provides valuable information on how to keep injections safe in your practice.
  • Mark multi-dose vials with the date they should be discarded (28 days after opening or sooner if recommended by the manufacturer). Immediately discard multi-dose vials if sterility is questioned or compromised. Discard all vials used during an emergency, as sterility cannot be guaranteed.
  • All injections should be double-checked by another nurse or medical assistant.
  • Practices should use safety needles.
  • Provide proper containers for the disposal of needles and syringes.
  • Document the site of administration of the injection.
• Allergies: Always ask about allergies and reactions to medications prior to administering medications.
• Vaccines:
  • Discard opened multi-dose vaccines according to the manufacturer’s expiration date.
  • Document in the patient’s medical record the name of the vaccine, lot number, expiration date, date administered or dispensed, site of administration, and name and title of person administering the vaccine.
  • Document the date that the vaccine information sheet (VIS) was given and parental authorization if indicated.
  • Document information on the immunization log as appropriate.
• Drug Devices: Aspiration of syringe tips can occur if parenteral syringes are used to administer or dispense liquid oral medications, and therefore, should not be used. Practices should use appropriate devices and train staff to use them correctly.

Dispensing

All medications should be stored in a locked location inaccessible to patients. Document daily temperature checks on medication refrigerators. No food, alcohol, or laboratory specimens should be stored in medication refrigerators.

Many office practices accept sample medications and dispense these medications to their patients. Patients generally appreciate receiving samples of newly prescribed medications so they can trial them before purchasing a full prescription. While this practice often promotes goodwill with patients, it can also present risks.

Sample medications dispensed to patients from an office practice do not benefit from a pharmacist’s review; therefore, extra care must be exercised when dispensing samples. Medical Mutual’s Practice Tip Medications: Distribution of Sample Medications in the Practice Setting provides detailed information on how to receive, store, and distribute sample medications.

Monitoring

Implement systems to monitor patients who have been prescribed high-alert medications (e.g., warfarin). High-alert medications often require ongoing lab monitoring and review of lab results to properly determine dosage. Systems should ensure that the patient’s test results are reviewed before prescribing renewals.

Resources

Agency for Healthcare Research and Quality. (n.d.). Guide to improving patient safety in primary care settings by engaging patients and families.

Centers for Disease Control and Prevention. (2014, July 14). About the One & Only campaign. https://stacks.cdc.gov/view/cdc/31801

CRICO Strategies. (2016). Medication-related malpractice risks: CRICO 2016 CBS benchmarking report. The Risk Management Foundation of the Harvard Medical Institutions Incorporated.

Institute for Safe Medication Practices. (2024, April 17). List of error-prone abbreviations.

Institute for Safe Medication Practices. (2018). List of high-alert medications in acute care settings.

Updated on: 2/2026