WHAT YOU NEED TO KNOW

In Pennsylvania, licensed healthcare facilities are required to report all events that cause harm or have the potential to cause harm to a patient.¹ The reports are captured in the Pennsylvania Patient Safety Reporting System (PA-PSRS) and then the Patient Safety Authority (PSA) analyzes them to identify causes or trends and share strategies to prevent harm. With over 5.8 million reports dating back to 2004, PA-PSRS is one of the largest data repositories of its kind in the world.²

Each year, PSA publishes an analysis of the acute and ambulatory care reports submitted to PA-PSRS, and this article expands on that work by highlighting the serious eventsa;1 reported to PA-PSRS with the Medication Error event type in 2025.²

In 2025, 82 facilities submitted a total of 303 serious Medication Error events to PA-PSRS. The most frequently reported Medication Error subtypes during this time frame are shown in Table 1.

 

Table 1. Frequency of Serious Medication Error Subtypes Reported to PA-PSRS in 2025

Medication Error Subtype

Note: Event subtypes with fewer than 10 reports are not shown in the table. Medication Error subtype “Other” had the highest frequency, with 49 reports; however, it is not shown in the table because it encompasses a variety of events, ranging from those that align with existing subtypes but were reported under the broader “Other” category to those that do not clearly align with a specific subtype, such as events involving reversal agent use and medication reconciliation issues.

As shown in Figure 1, high-alert medications were reported to PA-PSRS in association with serious Medication Error events at a proportion more than three times higher than for incidents^b;1 in 2025. Among the serious events, insulin was the most frequently reported high-alert medication, followed by opiates/narcotics and antithrombotic agents, as displayed in Figure 2.

It is important to note that, although nifedipine as an individual medication is not included in the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications³ and therefore not currently listed as a high-alert medication in PA-PSRS, it was involved in the same number of serious medication events as the entire class of high-alert benzodiazepines (5 reports). Previous PA-PSRS analyses have linked nifedipine-related errors to serious patient harm, including death.⁴

Figure 1. Percentage of High-Alert vs. Non-High-Alert Medications in Serious Medication Error Events and Incidents Reported to PA-PSRS in 2025 (N=303 for Serious Events, N=46,380 for Incidents)

Note: High-alert medications were reported in 47.2% (143 of 303) of the serious Medication Error events, compared with 14.6% (6,777 of 46,380) of the incidents reported to PA-PSRS in 2025.

Figure 2. Frequency of High‑Alert Medications in Serious Medication Error Events Reported to PA‑PSRS in 2025 (N=143)

 

Note: High-alert medications with fewer than 5 reports are not shown in the figure.

Analysis of serious Medication Error events reported to PA-PSRS in 2025 shows persistent, high-risk patterns. Insulin remains a major source of errors and inadvertent harm; PSA publications in 2025 identified insulin as the medication class most frequently involved in wrong-drug errors⁵ and associated it with large-scale overdoses resulting from syringe-related errors.⁶ Since our earlier newsletter highlighting fivefold wrong dose errors with U-500 insulin,⁷ the manufacturer has discontinued U-500 vials in the United States.^8,9 Wrong drug errors involving other medications also continue, including a fatal event in which 0.5 milligrams epinephrine was administered instead of 0.5 mg atropine, and an event in which 99% dehydrated alcohol was accidentally injected into a patient’s eye due to the alcohol sharing a storage location with the intended medication containing a mixture of lidocaine and epinephrine. Lastly, wrong-route errors persist. In one case, preservative-containing morphine was administered intrathecally (i.e., directly into the cerebrospinal fluid) at 10 times the intended dose despite the fact that intrathecal administration of preservative-containing morphine is contraindicated.10 In another case, sucralfate intended for administration via a feeding tube was given through a central line after instructions noting “oral vs tube administration” were interpreted as intravenous “tube” administration. These recurring themes highlight the ongoing need to revisit previously published strategies to mitigate wrong-route errors.^11,12

Although serious events comprise a small fraction of all medication errors reports submitted to PA-PSRS in 2025,² the potential for serious patient harm should not be underestimated: at least six reports were associated death or transition to comfort care. While high-alert medications were involved in almost half of the serious Medication Error events, serious patient harm can occur with the inappropriate use of any medication. Facilities are encouraged to reevaluate their current safety practices, identify any gaps in their workflow and protocols, and implement necessary changes to reduce the risk of serious patient harm associated with medication errors.

^aA serious event is defined as “an event, occurrence, or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional healthcare services to the patient.”

^bAn incident is defined as “an event, occurrence, or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional healthcare services to the patient.”

Disclosure

Artificial intelligence (Copilot Chat) was used only to improve sentence clarity. No AI was used for data analysis, interpretation, or generation of original content. The authors take full responsibility for the accuracy and integrity of the manuscript.

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2026 PA HAI Summit

The Pennsylvania Department of Health, Bureau of Epidemiology, and the Philadelphia Department of Public Health are pleased to present the 2026 Pennsylvania HAI Summit Strengthening Core Principles and Exploring New Innovations in Infection Prevention and Control.

This free virtual conference will be held on May 12 and 13 over two half days. The objective of the Summit is to provide Pennsylvania healthcare personnel from all facility types with updates on scientific advances related to healthcare-associated infections (HAIs), multidrug-resistant organisms, antimicrobial stewardship, and current Pennsylvania-specific epidemiologic data. Continuing education credits will be available.

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In conjunction with the Patient Safety Authority’s 2025 annual report, PSA took a close look at the 326,672 incidents and serious events reported last year by hospitals, ambulatory surgical facilities (ASFs), birthing centers, and abortion facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The total number of reports increased 3.6% from 2024 to 2025, while preliminary reporting rates for hospitals (32.0 reports per 1,000 patient days) and ASFs (10.9 reports per 1,000 surgical encounters) decreased by 0.5 points from 2024. This comprehensive review and analysis of 2025 PA-PSRS reports may indicate that year-to-year changes can be attributed to variations in reporting rather than broader shifts. PSA will continue to work with Pennsylvania healthcare facilities to enhance the quality of event reporting.

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In conjunction with the Patient Safety Authority’s 2025 annual report, PSA took a close look at the 30,967 healthcare-associated infections (HAIs) reported last year by long-term care facilities (e.g., nursing homes) to the Pennsylvania Patient Safety Reporting System (PA-PSRS). The total number of infection reports was a 16.9% increase from 2024 to 2025—the fourth consecutive annual increase—and the overall infection rate (1.25 infections per 1,000 resident days) was a 15.7% increase from the previous year, attributed to rising rates across all infection types, excluding device-related bloodstream infections. Of these, there were notable increases in respiratory tract infections, primarily due to a 117.7% increase in influenza reports, and gastrointestinal infections, which included an 84.7% increase in norovirus.

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Survey data show that communication between adult patients and healthcare providers about cannabinoid (CBD) use is often limited, which may increase the risk of drug–drug interactions with prescribed medications. In addition, nonprescription cannabinoids and medical marijuana (cannabis) currently lack Food and Drug Administration–approved prescribing information and standardized resources for evaluating potential interactions with other medication.​