GLP-1 Medication Risk Assessment
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Publication Date
4-29-2026
Keywords
oregon, ppmc, ppmc gme
Disciplines
Medical Education
Abstract
GLP‑1 receptor agonists are increasingly prescribed across diverse clinical settings. As overall utilization of these drugs increase, there has also been an associated uptick in reported patient safety concerns. Some of these reports have been associated with unconventional dosing schedules, product transitions, and evolving therapeutic uses. To assess these risks within PMG Oregon, a Common Cause Analysis (CCA) was conducted to evaluate all GLP‑1– related medication safety events reported between September 2023 and September 2025. A total of 27 events were identified, including near misses, precursor events, and patient‑reaching errors, and were analyzed by event type, MERP stage, contributing human factors, and system-level vulnerabilities. Most safety events originated during the prescribing or ordering stage, highlighting early workflow vulnerabilities related to incorrect dose selection, titration errors, and inappropriate starting doses when switching GLP‑1 products. Dispensing events represented the second most common category, while transcription errors occurred less frequently. These errors resulted in a range of patient outcomes—from no harm to significant gastrointestinal illness, dehydration, acute kidney injury, and emergency department visits. Human factor analysis demonstrated that consciousness-related lapses (IE: slips, inattention, interruptions) were the most frequently reported contributors, followed by critical thinking and competency-related errors. System-level contributors were dominated by policy and procedure gaps, process breakdowns, and technology limitations such as inappropriate EHR defaults and lack of automated guardrails. Issues related to storage and handling of Medication Assistance Program (MAP) products further reflected workflow vulnerabilities at individual clinics. Unfortunately, limited or incomplete documentation within the HRP events limits the ability to assess and identify patterns and characteristics fully. However, the analysis shows that GLP‑1 medication errors arise from intersecting human, workflow, and system factors. Opportunities for improvement include standardizing titration workflows, implementing EHR‑based safeguards, strengthening MAP handling processes, and clarifying caregiver roles to create a safer prescribing environment for GLP‑1 therapies. (IRB Exempt)
Specialty/Research Institute
Graduate Medical Education
Specialty/Research Institute
Internal Medicine
