Analysis of Serious Medication Error Events Reported to PA-PSRS in 2025

In Pennsylvania, licensed healthcare facilities are required to report all events that cause harm or have the potential to cause harm to a patient.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 events a;1 reported to PA-PSRS with the Medication Error event type in 2025. Medication Error SubtypesIn 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. a A 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."