Clinician reviews results from liquid sample

Experts in Medication Errors & Adverse Drug Events

Clinician reviews results from liquid sample

We provide trusted and independent expert analysis of patient safety matters across the healthcare ecosystem​

We serve as independent auditors for government and non-government organizations in the pharmacy, electronic prescribing, and EHR space. We have represented pharmacies, pharmacy vendors, hospitals, and EHR vendors in cases relating to medication and prescription errors.

medication-use system

Medication Errors and Root Cause Analysis

Medication Errors can occur at any point in the medication life-cycle. While errors cannot always be prevented, healthcare organizations can mitigate risks and reduce harm by implementing the necessary risk prevention strategies.

Impact in Numbers


The FDA receives more than 100,000 reports every year involving medication errors


Every year in the United States, more than 7,000 people die as a result of a medication error


Forty billion dollars is spent each year in the U.S. on patients affected by medication errors


Five percent of all malpractice claims can be attributed to medication errors

Key Definitions

Medication Error

“any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.” // National Coordinating Council for Medication Error Reporting and Prevention

Adverse Drug Event (ADE)

“an adverse outcome that can be attributed, with some degree of probability, to an action of a drug” // Drug Safety  volume 28, pages 851–870 (2005)

The occurrence of an adverse drug event defined above does not necessarily indicate an error or poor quality care.

Preventable ADEs

“result from a medication error that reaches the patient and causes any degree of harm; approximately half of ADEs are preventable.” // Agency for Health Research and Quality - Patient Safety Network

Adverse Drug Effect and Reaction

“an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product.” // Agency for Health Research and Quality - Patient Safety Network

Stated plainly, adverse drug effects and reactions are non preventable adverse drug events.

We are Clinicians, Technologists, and Patient Safety experts

Our Health IT experts understand the serious implications of Medication Errors and Adverse Drug Events, and how they threaten patient safety

We utilize our domain knowledge of in‑patient hospital systems (EHR), out‑patient systems (e‑prescribing/labs/EMR), and pharmacy management system software.

We draw on our extensive experience in designing and analyzing patient safety and clinical workflows, human factors engineering issues (user centric design), safety culture.

We apply formal analyses to establish whether standards of practice and safety procedures were appropriately constructed and implemented. We determine the root cause of medication errors and adverse drug events.

Our healthcare experts possess authoritative knowledge in many aspects of drug safety & pharmacovigilance

  • Electronic Prescribing of Controlled Substances
  • Prescription Dispensing Errors
  • Medication Errors
  • Patient Counseling
  • Drug Utilization Reviews
  • Electronic Health/Medical Records
  • Patient Safety Protocols, Policies, Procedures
  • Patient Safety Evaluation Systems
  • Patient Safety Risk Assessments
  • Risk Management Frameworks

Meet Our Medication Safety Experts

Ajit Dhavle

Ajit Dhavle, Pharm.D, MBA

VP of Health IT, Audits & Life Sciences Washington D.C.

Dr. Ajit Dhavle is a healthcare technologist, clinician, entrepreneur, and a problem solver with 20 years of experience in digital health, quality, e-medications, Health IT standards, and patient safety. He oversees a team of health informatics experts to provide strategy, management, SDLC, compliance, and audit services to government and commercial entities.

Health ITFocus AreaHealth IT & Life Sciences
Alicia Morton Farlese - Health IT Regulations Expert and Government Affairs Specialist

Alicia Farlese, DNP, RN-BC

Healthcare Regulations Expert Nashville

Alicia Morton Farlese is a retired Captain serving twenty-six years in the United States Navy Nurse Corps, and was a senior leader in national health IT policy at the US Dept. of Health and Human Services. Dr. Farlese assists clients in meeting Health IT regulations, including Information Blocking requirements of the Cures Act.

Health ITFocus AreaCompliance & Government Affairs

Speak With a Medication Safety Expert Today