Takeaway
Pause before prescribing—consider not only the correct dosage but also the patient’s finances and home support for managing the treatment.
Lifelong learning in clinical excellence | March 23, 2026 | 2 min read
By Anita Gupta, DO, PharmD, MPP, Johns Hopkins Medicine
The act of prescribing can feel like a routine digital check. However, medication safety is a critical component of our commitment to giving exceptional care to every patient. As recent high-profile tragedies demonstrate, the line between a routine dose and a fatal error remains dangerously thin.
Lessons from the headlines: the weight of a single dose
Clinical excellence isn’t just about the right diagnosis; it’s about ensuring the journey from the patient’s bedside to the prescription pad is paved with vigilance. We’re reminded of this by the tragic 2024 death of two-year-old De’Markus Page, who received a fatal overdose of potassium phosphate after a hospital missed a decimal point in his dosage. In another recent case study, an ICU patient died after being accidentally administered a vasopressor instead of an antibiotic because standard safety checks were bypassed.
These aren’t isolated incidents. Medication errors remain a leading cause of preventable harm, with ECRI’s 2025 reports highlighting deteriorating pharmacy working conditions and the dismissal of patient concerns as top patient safety threats.
Three pillars of reflective prescribing: reflective practices to prevent these medical errors:
1. The “Social Rx”check
Safety in prescribing is about more than dosage. It inclues the Social Rx—considering if the patient can afford the medication and if they have the support at home to manage it. If they don’t, connect them with financial resources and/or create an alternate medication plan.
2.Vigilance in new frontiers
Our commitment to excellence requires us to be perpetual students of new therapies. For example, the FDA recently issued alerts regarding massive dosing errors with compounded GLP-1 drugs like semaglutide, where some patients mistakenly took up to 20 times the intended dose.
3. Listen when a patient expresses hesitation.
A patient’s intuition that something “doesn’t feel right” is a vital clinical data point. Take the time to talk with them to discover what’s feeling off.
AI: a double-edged sword
As we look to the future, AI tops the list of both health technology hazards and solutions. While AI tools can reduce medication errors by providing real-time alerts and confirming medication IDs, they also introduce new risks through insufficient governance and software mislabeling.
The conversation continues
Drug safety is a team effort requiring a “no-blame” culture. The legacy of the RaDonda Vaught case—the nurse criminally prosecuted for a fatal medication error—continues to spark debate about whether a punitive approach causes a “chilling effect” on error reporting.
True excellence means prioritizing psychological safety over hierarchy, ensuring that every member of the team—including, of course, the patient—feels empowered to speak up when something doesn’t seem right.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.