Every year, tens of thousands of people in the U.S. die because of medication errors. Not because of bad intentions, but because systems failed. A nurse grabs the wrong vial. A pharmacist misreads a handwritten script. A barcode scanner doesn’t catch a mismatch. These aren’t rare mistakes-they’re symptoms of broken processes. And they’re preventable.

What Are the National Patient Safety Goals (NPSGs)?

The National Patient Safety Goals, set by The Joint Commission, are not suggestions. They’re mandatory standards for nearly every hospital in the U.S. First launched in 2003, they were created after the Institute of Medicine’s landmark report To Err is Human revealed that medical errors cause up to 98,000 deaths annually. Medication errors alone account for about 250,000 deaths each year-making them one of the top causes of death in America.

These goals focus on six areas, but the most critical for pharmacies is medication safety. The 2025 NPSGs have sharpened their focus on high-risk moments: when drugs are labeled, dispensed, administered, or reconciled. For example, NPSG.03.04.01 demands that every medication container-whether it’s a syringe on an operating table or a vial in a pharmacy-must be labeled with the drug name, strength, concentration, and expiration date. The font size? Minimum 10-point. No exceptions.

It sounds simple. But a 2023 survey found that 27% of operating rooms still use unlabeled syringes. That’s not negligence-it’s a system flaw. When staff are rushed, understaffed, or trained poorly, they cut corners. The NPSGs exist to force systems to change, not to blame individuals.

High-Alert Medications: The Silent Killers

Not all drugs are created equal. Some are so dangerous that even a small mistake can kill. These are called high-alert medications. They include insulin, heparin, opioids, and concentrated electrolytes like potassium chloride.

The Institute for Safe Medication Practices (ISMP) tracks these risks closely. Between 2006 and 2018, injectable promethazine-used for nausea-caused 37 amputations because it was accidentally given into an artery instead of a vein. That’s not a rare event. It’s predictable. And it’s preventable.

The 2025 NPSGs now require hospitals to have specific protocols for high-alert drugs. That means:

• Double-checking doses before dispensing
• Storing them separately from other medications
• Using automated dispensing cabinets (ADCs) with locked access
• Training every pharmacist and nurse on their risks

But here’s the catch: ADCs are only as good as their override policies. Pharmacists report that 34% of facilities have override rates above 5%. Why? Because someone needs a stat dose during a code. But every override is a risk. Facilities with override rates over 5% have 3.7 times more medication errors. The fix? Not banning overrides. It’s designing systems that make safe choices easier. Like pre-loading emergency doses in locked trays or using AI to flag dangerous combinations before they’re ordered.

Why the Five Rights Are Not Enough

You’ve heard them: right patient, right drug, right dose, right route, right time. They’re taught in every nursing school. But here’s the truth: 83% of medication errors happen even when all five rights are checked.

Why? Because the Five Rights put the burden on the person holding the syringe-not the system that made the mistake possible. A nurse working a 12-hour shift with eight patients doesn’t have time to cross-check every label three times. She’s tired. She’s distracted. She’s counting on the system to protect her.

The Institute for Healthcare Improvement (IHI) says the Five Rights are a checklist, not a safety strategy. Real safety comes from:

• Barcode scanning at the bedside
• Electronic prescriptions that auto-calculate doses
• Automated dispensing cabinets that block incorrect selections
• Pharmacist-led medication reconciliation at every transition of care

At Children’s Hospital of Philadelphia, they redesigned their pediatric dosing system. Instead of relying on nurses to calculate weight-based doses manually, they built electronic alerts that auto-populate doses based on the child’s weight. Result? A 91% drop in dosing errors. That’s not luck. That’s engineering safety into the workflow.

Technology That Works-And What Doesn’t

Technology is supposed to help. But not all tech is created equal.

Barcode-assisted medication administration (BCMA) is one of the most effective tools. Hospitals that use it see up to an 86% reduction in wrong-drug errors. But there’s a trade-off: nurses report spending 7.2 extra minutes per dose scanning barcodes. That’s a lot when you’re juggling 20 patients. Some hospitals tried to cut corners by letting staff scan from a distance or skip steps. That’s when errors creep back in.

The real winners? Hospitals that pair BCMA with adequate staffing and training. They don’t just install the scanner-they redesign the workflow around it. They assign pharmacists to monitor alerts. They train nurses on what to do when the system flags a problem. And they don’t punish staff for stopping the process when something looks wrong.

Automated dispensing cabinets (ADCs) are another example. They’re great for tracking inventory and preventing theft. But if staff can override them too easily, they become a liability. The 2025 NPSGs now require hospitals to audit override logs monthly and investigate every pattern of abuse. Some hospitals now use AI to predict when overrides are likely-like during night shifts or when a specific nurse is on duty-and send real-time alerts to pharmacists.

Who’s Responsible? The Culture Shift

Blaming the pharmacist for a mislabeled vial won’t fix the problem. Blaming the nurse for a wrong dose won’t stop the next one. Real change happens when leadership takes ownership.

Dr. Michael Cohen, former president of ISMP, says the NPSGs are the bare minimum. “They’ve saved lives,” he says, “but they’re not best practices.” Best practices come from a culture where:

• Pharmacists have a seat at the executive table
• Errors are reported without fear of punishment
• Staff are trained not just on procedures, but on why they matter
• Leaders review error data every quarter-not just to check compliance, but to fix systems

At Johns Hopkins, pharmacy leaders helped create a controlled formulary based on safety-not cost. They removed dangerous drugs from stock unless absolutely necessary. They replaced high-risk medications with safer alternatives. Result? A 40% drop in adverse drug events in just two years.

This isn’t about more rules. It’s about better systems. And it starts when hospital CEOs stop treating safety as a compliance checkbox and start treating it as a core value.

What’s Changing in 2025?

The 2025 NPSGs introduce two major updates:

1. Bedside specimen labeling: Labels on blood tubes must be applied in front of the patient, using two identifiers (name and date of birth). This cuts down on mislabeled samples-currently a cause of 160,000 errors a year.
2. ADC override limits: Hospitals must now prove they’re actively reducing overrides through training, audits, and system redesign-not just setting a 5% target and hoping for the best.

Outside the U.S., Australia’s ASHP guidelines focus on system-level fixes: standardized procedures, mandatory training, and regular error reviews. The World Health Organization is pushing for global adoption of these standards by 2030. But only 22% of low-income countries have them.

The future? AI. Mayo Clinic’s pilot program uses machine learning to predict which patients are at risk for adverse drug events based on their history, current meds, and lab results. They reduced potential errors by 47%. That’s not science fiction. It’s happening now.

How to Start Improving Your Pharmacy’s Safety

If you’re a pharmacist, manager, or administrator, here’s where to begin:

1. Map your high-risk processes. Where do errors happen most? Is it during handoffs? Labeling? Overrides? Track it for a month.
2. Adopt one new safety tool. Start with barcode scanning if you don’t have it. Or implement double-checks for high-alert drugs.
3. Train, don’t just inform. Don’t hand out a 10-page policy. Run a 30-minute role-play: “What if the barcode doesn’t scan? What if the dose looks wrong?”
4. Measure what matters. Track override rates, labeling compliance, and error reports-not just “compliance scores.”
5. Ask your staff. They know where the system breaks. Listen to them. Reward them for speaking up.

There’s no magic bullet. But small, consistent changes-backed by data and leadership-add up. The goal isn’t perfection. It’s progress. And every error prevented is a life saved.

What Comes Next?

The next five years will see more automation, more AI, and more pressure to prove safety isn’t just a policy-it’s a practice. Hospitals that treat medication safety like a financial metric-tracking it, funding it, and rewarding it-will outperform those that treat it as a regulatory burden.

The data is clear: systems prevent errors. People prevent disasters. And when the two work together-when technology supports human judgment, and leadership backs up frontline staff-medication errors stop being inevitable. They become rare. And that’s the goal.