Medical errors are one of the Nation’s

leading causes of death and injury. A

recent report by the Institute of

Medicine estimates that as many as

44,000 to 98,000 people die in U.S.

hospitals each year as the result of medical errors. This means that more people die from medical errors than from

motor vehicle accidents, breast cancer,

or AIDS.

Government agencies, purchasers of

group health care, and health care

providers are working together to make

the U.S. health care system safer for

patients and the public. This fact sheet

tells what you can do.

What are Medical Errors?

Medical errors happen when something

that was planned as a part of medical

care doesn’t work out, or when the

wrong plan was used in the first place.

Medical errors can occur anywhere in

the health care system: in hospitals,

clinics, outpatient surgery centers, doctors’ offices, nursing homes, pharmacies, and patients’ homes. Errors can

involve medicines, surgery, diagnosis,

equipment, or lab reports. They can

happen during even the most routine

tasks, such as when a hospital patient

on a salt-free diet is given a high-salt

meal. 

Most errors result from problems created by today’s complex health care system. But errors also happen when doctors and their patients have problems

communicating. For example, a recent

study supported by the Agency for

Healthcare Research and Quality found

that doctors often do not do enough to

help their patients make informed decisions. Uninvolved and uninformed

patients are less likely to accept the doctor’s choice of treatment and less likely

to do what they need to do to make the

treatment work. 

What Can You Do? Be Involved

in Your Health Care

The single most important way you

can help to prevent errors is to be an

active member of your health care

team. That means taking part in every

decision about your health care.

Research shows that patients who are

more involved with their care tend to

get better results. 

Here are some specific tips, based on

the latest scientific evidence about what

works best:

AHRQ is the lead agency charged with 

supporting research designed to improve the

quality of health care, reduce its cost, address

patient safety and medical errors, and 

broaden access to essential services. AHRQ 

sponsors and conducts research that provides

evidence-based information on health care outcomes; quality; and cost, use, and access. The

information helps health care decisionmakers—

patients and clinicians, health system leaders,

and policymakers—make more informed 

decisions and improve the quality of health 

care services.

20 Tips To Help Prevent

Medical Errors

Agency for Healthcare Research and Quality • 2101 East Jefferson Street • Rockville, MD 20852

PATIENT FACT SHEET

U.S. Department of Health 

and Human Services

Public Health Service
Medicines

Make sure that all of your doctors

know about everything you are taking. This includes prescription and

over-the-counter medicines, and

dietary supplements such as vitamins

and herbs. At least once a year, bring

all of your medicines and supplements

with you to your doctor. “Brown bagging” your medicines can help you and

your doctor talk about them and find

out if there are any problems. It can

also help your doctor keep your records

up to date, which can help you get better quality care.

Make sure your doctor knows about

any allergies and adverse reactions

you have had to medicines. This can

help you avoid getting a medicine that

can harm you. 

When your doctor writes you a prescription, make sure you can read it.

If you can’t read your doctor’s handwriting, your pharmacist might not be able

to either. 

Ask for information about your medicines in terms you can understand–

both when your medicines are prescribed and when you receive them:

• What is the medicine for?

• How am I supposed to take it, and

for how long?

• What side effects are likely? What

do I do if they occur?

• Is this medicine safe to take with

other medicines or dietary supplements I am taking?

• What food, drink, or activities

should I avoid while taking this

medicine?

When you pick up your medicine

from the pharmacy, ask: Is this the

medicine that my doctor prescribed?

A study by the Massachusetts College

of Pharmacy and Allied Health Sciences

found that 88 percent of medicine

errors involved the wrong drug or the

wrong dose.

If you have any questions about the

directions on your medicine labels,

ask. Medicine labels can be hard to

understand. For example, ask if “four

doses daily” means taking a dose every

six hours around the clock or just during regular waking hours.

Ask your pharmacist for the best

device to measure your liquid medicine. Also, ask questions if you’re not

sure how to use it. Research shows that

many people do not understand the

right way to measure liquid medicines.

For example, many use household teaspoons, which often do not hold a true

teaspoon of liquid. Special devices, like

marked syringes, help people to measure the right dose. Being told how to

use the devices helps even more.

Ask for written information about

the side effects your medicine could

cause. If you know what might happen,

you will be better prepared if it does–or,

if something unexpected happens

instead. That way, you can report the

problem right away and get help before

it gets worse. A study found that written information about medicines can

help patients recognize problem side

effects and then give that information

to their doctor or pharmacist.

Make sure that all of your doctors

know about everything you are 

taking. This includes prescription

and over-the-counter medicines,

and dietary supplements such 

as vitamins and herbs.

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Hospital Stays

If you have a choice, choose a hospital at which many patients have the

procedure or surgery you need.

Research shows that patients tend to

have better results when they are treated

in hospitals that have a great deal of

experience with their condition.

If you are in a hospital, consider asking all health care workers who have

direct contact with you whether they

have washed their hands.

Handwashing is an important way to

prevent the spread of infections in hospitals. Yet, it is not done regularly or

thoroughly enough. A recent study

found that when patients checked

whether health care workers washed

their hands, the workers washed their

hands more often and used more soap.

When you are being discharged from

the hospital, ask your doctor to

explain the treatment plan you will

use at home. This includes learning

about your medicines and finding out

when you can get back to your regular

activities. Research shows that at discharge time, doctors think their

patients understand more than they

really do about what they should or

should not do when they return home. 

Surgery

If you are having surgery, make sure

that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. Doing surgery at

the wrong site (for example, operating

on the left knee instead of the right) is

rare. But even once is too often. The

good news is that wrong-site surgery is

100 percent preventable. The American

Academy of Orthopaedic Surgeons

urges its members to sign their initials

directly on the site to be operated on

before the surgery. 

Other Steps You Can Take

• Speak up if you have questions or

concerns. You have a right to question anyone who is involved with

your care.

• Make sure that someone, such as

your personal doctor, is in charge

of your care. This is especially

important if you have many health

problems or are in a hospital.

• Make sure that all health professionals involved in your care have

important health information

about you. Do not assume that

everyone knows everything they

need to. 

• Ask a family member or friend to

be there with you and to be your

advocate (someone who can help

get things done and speak up for

you if you can’t). Even if you think

you don’t need help now, you might

need it later.

• Know that “more” is not always

better. It is a good idea to find out

why a test or treatment is needed

and how it can help you. You could

be better off without it.

• If you have a test, don’t assume

that no news is good news. Ask

about the results.

• Learn about your condition and

treatments by asking your doctor

and nurse and by using other reliable sources. For example, treatment recommendations based on

the latest scientific evidence are

available from the National

If you are having surgery, make 

sure that you, your doctor, and your

surgeon all agree and are clear on

exactly what will be done.

3
Guideline Clearinghouse at

(www.guideline.gov). Ask your doctor if your treatment is based on the

latest evidence.

For more information about medical

errors, see AHRQ’s Web site at

http://www.ahrq.gov/errors.htm. Or

call the AHRQ Clearinghouse at 1-800-

358-9295 for a Federal report on medical errors (Pub. No. OM00-0004).

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AHRQ Pub. No. 00-P038

September 2000