
Medication Errors: Understanding the Causes and Designing Effective Risk Management Strategies
Overview
The purpose of this module is to engage health care providers (prescribers), pharmacists, and other health care professionals in evidence based practices to avoid medication errors and enhance patient safety. Successful attainment of knowledge by the learner will enable improved awareness and lead to changes in clinical practice measures to overcome common causes of medication errors.
Target Audience
This activity is intended for physicians, nurses, pharmacists, and other healthcare professionals.
Learning Objectives
Upon completion of this module, the learner should be able to:
- Establish an understanding of contributing factors and epidemiology of medication-related patient safety events
- Discuss on current research on causality (root cause analysis) and human factors design features to mitigate them
- Review of best practice approaches in reducing errors in the inpatient and ambulatory setting (clinic and pharmacy)
- Identify systems level innovations in risk management strategies that can be used to minimize or prevent medication errors and equip professionals to manage the consequences when they occur
Course summary
- 2.00 ACPE Pharmacist
- 2.00 ACPE Pharmacy Technician
- 2.00 AMA PRA Category 1 Credit™
- 2.00 Nursing Hours
- 0.20 IACET CEUs
Allen J. Vaida PharmD, FASHP
Executive Vice President, Institute for Safe Medication Practices
Allen J. Vaida, BSc, PharmD, FASHP, is Executive Vice President at the Institute for Safe Medication Practices (ISMP), where he helps advance the organization’s mission, strategic priorities, partnerships, and impact. A longtime advocate for medication safety, Dr. Vaida previously held pharmacy and executive leadership roles at Mercy Suburban Hospital and has served on national committees including the United States Pharmacopeia’s Safe Medication Use Expert Committee and the FDA Pharmacy Compounding Advisory Committee. He has also held academic appointments at several universities and has published and presented extensively on medication safety, error prevention, healthcare systems, and interdisciplinary collaboration. Dr. Vaida earned degrees from the University of Scranton, Philadelphia College of Pharmacy and Science, and the University of Minnesota.
Raj M. Ratwani, PHD
Director, MedStar Health National Center for Human Factors in Healthcare
Vice President of Scientific Affairs, MedStar Health Research Institute
Raj is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at the Georgetown University School of Medicine. As director, he oversees the Center’s vision and strategy and has overall responsibility for Center activities. He is also an active applied researcher serving as principal investigator on numerous grants and contracts, including three research project grant (R01) awards from the U.S. Department of Health and Human Services (HHS), which are among the most prestigious grants. Raj has expertise in health information technology, usability and safety, interruptions and workflow, data visualization, and modeling. Raj’s research has been funded by the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health (NIH), The Pew Charitable Trusts, and industry partners. His work has been published in high-impact journals such as The Journal of the American Medical Association (JAMA) and Health Affairs and has influenced both policy and frontline clinical practice. His research has been featured by Politico, Fortune, Kaiser Health News, National Public Radio (NPR), and many other media outlets. He serves on the federal 21st Century Cures Act Health Information Technology Advisory Committee and has testified to the U.S. Senate Health, Education, Labor, and Pensions Committee. He holds a doctorate in human factors and applied cognition and was a National Research Council post-doctoral fellow at the U.S. Naval Research Laboratory.
Marybeth Kazanas, PharmD, BCPS, LSSGB
Director of Clinical Pharmacy Services at Medstar Health
Marybeth Kazanas, PharmD, BCPS, is System Director of Clinical Pharmacy Services at MedStar Health, where she oversees clinical pharmacy programs across the system and co-chairs committees focused on medication safety, antimicrobial stewardship, and interprofessional continuing education. She works closely with pharmacy and physician leadership to improve medication management and has held several clinical and leadership roles within MedStar. Her professional interests include medication safety, high-cost medication management, and professional development. Dr. Kazanas earned her Doctor of Pharmacy from Duquesne University, completed a pharmacy practice residency at Hahnemann University Hospital, and is a board-certified pharmacotherapy specialist with Lean Six Sigma certification.
Eileen Ruth Langstraat, Pharm.D., BCPS, CPPS
Pharmacy Medication and Patient Safety Coordinator
Eileen R. Langstraat, Pharm.D., BCPS, is the pharmacy medication and patient safety coordinator at Kaiser Permanente, Rockville, Maryland. She received her bachelor of arts degree in biochemistry from Saint Mary’s College of Maryland in 2009 and her doctor of pharmacy degree from Shenandoah University in 2015. Dr. Langstraat completed an ASHP-accredited postgraduate year 1 pharmacy residency at Johns Hopkins Bayview Medical Center in 2016, where she subsequently completed a medication-use safety residency. Her current research interests include medication safety and medication-use process quality improvement.
Georgia Lewis,MSN, RN, CPNP-PC
Pediatric Nurse Practitioner
Georgia Lewis is a pediatric nurse practitioner focused on improving the health of underserved patients and communities as a primary care provider. She was a HRSA Nurse Corps scholarship recipient for her MSN degree at Johns Hopkins University and recently received a 2020 National Health Service Corps award. She has a background in studio art and as a labor and postpartum doula. Currently she is serving at an FQHC in the Cleveland, Ohio metropolitan area working with a predominantly Spanish-speaking immigrant population
Seth A. Krevat, MD
Assistant vice president for Safety, MedStar Health
Faculty Associate, MedStar Health’s National Center for Human Factors in Healthcare
Attending physician, Palliative Medicine, MedStar Georgetown University Hospital
Dr. Krevat is Assistant Vice President for Safety at MedStar Health, where he oversees patient and staff safety, risk reduction, and clinical documentation improvement initiatives across acute and non-acute care settings. He leads programs focused on reducing safety risks, responding to serious safety events, and improving performance against internal and external safety requirements. Dr. Krevat serves on several MedStar leadership and quality committees and has presented nationally on patient safety, event data, and the use of human factors engineering in risk reduction. He is board certified in internal medicine and hospice and palliative medicine.
Misty Carney, B.S., PharmD., AAHIVP
Chief, Maryland AIDS Drug Assistance Program
Misty Carney is a credentialed HIV pharmacist with the American Academy of HIV Medicine and more than 10 years of experience in infectious disease and public health. An alumna of Tennessee State University, Howard University School of Pharmacy, and the University of Maryland School of Public Health, she was inspired to work in HIV care by her family’s personal experience with the disease and her mother’s community-based HIV education and stigma-reduction efforts in rural West Tennessee. Misty serves on the Washington, D.C. Regional Planning Commission on Health and HIV and is a pharmacy student preceptor at Howard University. Her work focuses on education, community engagement, and improving outcomes for people living with HIV across the Washington, D.C. metropolitan area and Maryland.
Donna Horn, MS, RPh, DPh, CHC
Pharmacy Ethics and Compliance Officer at Fresenius Medical Care North America
Donna Horn has over 10 years experience in medication safety, 20 years experience in retail/ chain pharmacy, and over 15 years of national pharmacy regulatory experience; She wrote regulations and programs for CQI, QAP, RCA and FMEA; Masters of Science Degree in Pharmacy, concentration in Pharmaceutical Outcomes and Policy with certificate in Patient Safety and Medication Risk Management; emphasis in patient safety and ethics of drug product, distribution, and use; adjunct faculty at MCPHS Univ and guest lecturer at many colleges of pharmacy nationwide. Expert Witness for Standards of Practice in Pharmacy, including medication error analysis and wrongful death cases; extensive knowledge of medication safety practices, pharmacy operations and pharmacy regulations affecting mail-order and community/ambulatory practice sites. Experience with all boards of pharmacy: Past President of MA Board of Pharmacy, Past President and Chairman of National Association of Boards of Pharmacy; HIPAA Privacy Officer for large chain pharmacy.
Relevant Financial Relationships
The instructors, advisors, panelists, and planners of the course have no relevant financial relationships to declare.
Anti-discrimination Policy
The instructors, advisors, panelists, and course planners have agreed to our anti-discrimination policy that prohibits the inclusion of discriminatory language, graphics, or references on the basis of race, gender identity, age, color, national origin, physical or mental disability, or religion.
In October 2026, this course content was reviewed and its accreditation has been renewed through October of 2029.
PHARMACISTS AND PHARMACY TECHNICIANS
Innovation Horizons is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. Innovation Horizons designates this enduring material for:
ACPE Pharmacist: (2.0 Contact Hour) UAN: JA4008411-0000-26-012-H05-P
ACPE Pharmacy Technician: (2.0 Contact Hour) UAN: JA4008411-0000-26-012-H05-T
PHYSICIANS – AMA CREDIT DESIGNATION STATEMENT
Innovation Horizons designates this enduring activity for a maximum of 2.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AMA PRA Category 1 Credit™
NURSES – ANCC CREDIT DESIGNATION STATEMENT
Innovation Horizons designates this enduring activity for a maximum of 2.0 ANCC contact hours. Nursing contact hours will be awarded for successful completion of program components based upon documented attendance and completion of evaluation materials
JOINT ACCREDITATION

In support of improving patient care, Innovation Horizons is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
IPCE CREDITS

This activity was planned by and for the healthcare team, and learners will receive 2.0 Interprofessional Continuing Education (IPCE) credits for learning and change.
MIPS
This activity is registered as a MIPS Improvement Activity (IA_PSPA_28). To qualify, learners must complete all activity components, including follow-up surveys. MIPS-eligible clinicians may attest in the CMS Quality Payment Program.

Available Credit
- 2.00 ACPE Pharmacist
- 2.00 ACPE Pharmacy Technician
- 2.00 AMA PRA Category 1 Credit™
- 2.00 Nursing Hours
- 0.20 IACET CEUs
Required Hardware/Software
High-Speed Internet Connection
Adobe Reader for PDF file download
Browser:
- This educational activity has been tested in the latest versions of Edge, Firefox, Safari, and Chrome browsers on Windows or Macintosh computers.
- The Safari, Firefox, or Chrome browsers are recommended for best results.
- The Internet Explorer browser is not recommended as it is no longer supported by Microsoft.

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