While systemic factors like high workloads, understaffing, and communication breakdowns drive medical errors across all of healthcare, special populations face unique, compounded vulnerabilities. For these groups, standard safety protocols are often insufficient because their physiologic, cognitive, communication, or socioeconomic needs deviate differ from those of an “average” patient.

Some medications and procedures can be harmful for any given patient. There are some groups, however, that have an increased risk of adverse events. Children, elders, and those with limited English skills and/or poor health literacy are at a high risk for adverse events. Addressing these risks requires tailored, population-specific interventions.

6.1 Pediatric Patients: Dosing and Dependency

The landmark To Err Is Human report highlighted that children are at a particularly high risk for medication errors, primarily related to weight-based calculations.

Unlike adults, pediatric medication requires complex calculations based on weight (mg/kg), body surface area, or age. A simple misplaced decimal point can easily result in a 10-fold (10x) dosing error. Furthermore, hospitalized children under five years are physiologically fragile and have a narrower therapeutic window to tolerate adverse drug events.

Mandating the use of the metric system (grams/milligrams and milliliters) across all electronic health records can eliminate confusion and provide precise clinical measurements. Because children are entirely dependent on caregivers to relay history and monitor symptoms, systems must actively integrate parents into the “time-out” and bedside handoff processes.

6.2 Geriatric and Frail Elderly Patients: Polypharmacy and Functional Decline

Adverse drug reactions (ADRs) in older adults are a significant, largely preventable public health challenge. As the body ages, its relationship with pharmaceuticals changes due to a combination of physiologic shifts and complex medical profiles. The single greatest predictor of an adverse drug reaction is polypharmacy, typically defined as taking five or more daily medications.

For older adults, preventing unnecessary adverse drug events associated with the use of inappropriate medications or polypharmacy is especially important. Deprescribing* to reduce polypharmacy and use of the STOPP criteria to reduce potentially inappropriate medications are two important approaches. Deprescribing has the potential to help providers adjust down or eliminate medications based on the condition and needs of a patient (Earl et al., 2020).

*Deprescribing: tapering or stopping medications where the potential harms outweigh the clinical benefits within the context of an individual patient's current life expectancy and care goals.

Many medications—including over the counter (OTC) antihistamines, tricyclic antidepressants, and drugs for urinary incontinence—possess strong anticholinergic properties. They block acetylcholine, a critical neurotransmitter for memory and muscle function. In older adults, this creates an anticholinergic burden characterized by:

• central effects: confusion, memory impairment, delirium, and hallucinations
• peripheral effects: dry mouth, blurred vision, constipation, and acute urinary retention

Routine utilization of screening tools like the Beers Criteria helps healthcare providers identify and if needed, discontinue potentially inappropriate medications.

Patient falls are one of the most common adverse events in hospitals. They are typically the result of a convergence of risk factors, with pharmacology being one of the most modifiable variables. Medications that significantly elevate fall risk include:

• psychotropics (benzodiazepines, sedatives, hypnotics, antipsychotics, antidepressants)
• cardiovascular agents (antihypertensives, diuretics, nitrates)
• anticholinergics (older antihistamines, overactive bladder medications)

6.3 Limited English Proficiency

Nearly 26 million individuals in the United States have limited English proficiency, defined as the ability to speak English “less than very well.” In the United States, individuals with limited English proficiency have a legal right to access healthcare in their preferred language. Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color, or national origin and mandates the provision of interpreter services by agencies receiving federal financial assistance, which includes hospitals that receive Medicaid and Medicare reimbursement (Sliwinski et al., 2024).

Language barriers can affect communication between patients and healthcare staff and are associated with lower quality of care. Individuals with limited English proficiency experience lower satisfaction with care, longer lengths of stay, and increased hospital readmissions compared with those who are English-proficient (Sliwinski et al., 2024).

6.4 Historically Marginalized and Low-Income Populations

When we look at how historically marginalized and low-income populations experience healthcare, the harm isn't just about an individual having a bad experience with a healthcare provider. It is a compounding systemic issue where social factors, financial barriers, and implicit biases intersect to produce vastly different health outcomes.

People from marginalized ethnic backgrounds are more likely to be harmed by healthcare because of interpersonal and structural factors that shape their care experiences. These factors include ineffective communication during clinical care, implicit biases among healthcare providers, and medical educational and clinical treatment approaches designed around White patient populations as the norm (Wade et al., 2022).

For low-income and marginalized individuals, the harm often starts long before they even see a healthcare provider. A person who is uninsured or under-insured is at a disadvantage; high deductibles and co-pays also force many to ration their care. This leads to delayed diagnoses, wherein preventable conditions (like hypertension or early-stage cancers) go untreated until they become life-threatening emergencies.

Many people live in neighborhoods or rural areas with few hospitals, clinics, and pharmacies. A resident in a low-income urban area might have transportation costs to reach a specialist, creating barriers and complicating follow-up care.

Once inside the clinic or hospital, marginalized and low-income people frequently receive a lower standard of care due to systemic racism, cultural disconnects, and implicit biases. Language and cultural barriers can lead to a higher rate of diagnostic and medication errors.

A striking example of systemic harm is related to maternal mortality. Pregnancy-related mortality rates among Black women are over three times higher than the rate for White women. Black, American Indian, Alaska Native, and Native Hawaiian or Pacific Islander women also have a higher percentage of preterm births, low birthweight births, or births for which they received late or no prenatal care compared to White women. Theses infants have markedly higher mortality rates than those born to White people (Hill et al., 2025).

Crucially, this disparity persists even when controlling for income and education, proving that clinical bias—such as providers minimizing or ignoring the self-reported symptoms of Black patients—plays a direct role.