Running head: MEDICATION ERRORS 1

Medication Errors

Sarah Gift

University of South Florida

Medication Errors

A medication error can be defined as any preventable event that may or may not harm a

patient as the result of a mis-step in the medication administration process. Errors can happen in

any phase of the medication use process, including prescribing, dispensing, administrating, and

monitoring. From prescriber to patient, best practice dictates that there is a series of independent

checks and balances within the healthcare system that work to prevent medication errors from

occurring. However, in this system of checks and balances, the nurse is the last step before the

patient. As the last human safety net, nurses have an immense responsibility when it comes to

medication administration and it is essential that they take the opportunity to detect and correct

errors. Although changes have been made in the safety of prescribing and administering of

medications, errors still occur and can have a profound impact on patients and families.

Common Medication Errors

Recognizing common medication errors is the first step to preventing them from

reoccurring. Examples of common medication errors include administering the incorrect drug,

the incorrect dose, and via the incorrect route. Administering the wrong medication can be the

result of a physician prescribing the wrong medication in the first place. A study conducted by

the Clinical Pharmacy Department at a Paris hospital found that computerized provider order

entry systems are potential sources of error in medication administration (Korb-Savoldelli,

Boussadi, Durieux, & Sabatier, 2018). While these systems streamline the prescription process

by eliminating problems like those associated with poor provider handwriting or transcription,

they pose new problems like selecting the wrong medication from a drop-down menu or

incorrectly entering keyboard shortcuts. These minute mis-steps in a seemingly fool-proof

system contribute to the continued incidence of medication errors related to giving the incorrect
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medication. However, this type of error could also be the result of a nurse pulling the wrong

medication, bypassing a bar code system if one is available, or overriding the electronic checks

in the case of an emergency before giving the medication.

Administering the wrong dose, especially when doses are weight based, is another

common medication error. This can occur from prescribing an incorrect dose, calculating an

incorrect dose, or pulling the incorrect dose. In a recent study, Rishoej, Almarsdottir, Christesen,

Hallas, & Kjeldsen (2017) found that the “wrong dose” errors accounted for more than half of all

pediatric medication errors. This study emphasizes the fact that, while weight-based dosing is the

standard of pediatric medications, it presents a heightened opportunity for error.

Medication errors can also occur when medications are administered by a route other

than the one that was prescribed. This can happen if a nurse draws up a medication and delivers

it parenterally instead of intramuscularly or subcutaneously, or by delivering an oral liquid

medication intended to be given through an enteral feeding tube into a parenteral IV line instead.

Although medication errors can occur in numerous ways, they have a basis in human (i.e.

distraction, poor concentration, multitasking), machine (i.e. unclear computerized prescription),

material (i.e. similar names, similar packaging), or environmental sources (i.e. medications next

to each other, unorganized work environments) (Chen et al., 2019).

Impact on Patients and Families

The common medication errors of administering the wrong medication, incorrect dose, or

via an alternate route can have a profound impact on patients and families. Each of these errors

has the potential to cause patient harm, whether it be mild or severe. Administering the wrong

medication may be harmful because the patient could be allergic to it or it could negatively

interact with other medications the patient may be taking. Administering the incorrect dose of a
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medication may result in a patient not receiving enough of a medication and not achieving a

therapeutic effect, or worse, the patient receiving too much and enduring toxic effects.

Administering a medication via an alternate route can cause site pain if a drug is inappropriately

injected or gastrointestinal distress if accidentally administered orally. Severe toxic effects can

manifest in the case of administering a medication via an alternate route, as medications often

have different concentrations depending on their route. Also, oral liquid preparations are not a

sterile and can increase the risk of infection if they are inadvertently given intravenously.

In addition to compromising patient safety and standards of care, medication errors may

have a direct impact the patient’s current disease prognosis by causing a change in their

condition and further delaying discharge. By delaying discharge, strain might be placed on the

patient’s physical, mental, and financial well-being. It is necessary to consider the patient’s

family in relation to medication errors. Whether these errors significantly harm the patient or not,

it is likely that both the patient and their family could lose trust in the healthcare team.

Significant harm or death resulting from a medication error is the worst possible scenario for

patients, families, and caregivers. It is important that the hospital team caring for that patient,

with assistance from risk management, meet with the family, disclose what happened, apologize,

and talk about changes that will be put in place to prevent similar errors to be made in the future.

Avoiding Medication Errors

By recognizing common medication errors, identifying underlying causes, and

understanding the impact that they can have on patients and their families, nurses and other

healthcare professionals can work to prevent them from happening. As a nurse, performing the

six rights of medication administration is essential to appropriately administering medications

and avoiding medication errors. The six rights include verifying the right patient, right drug,
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right dose, right route, right time, and right documentation before administering a medication.

The use of barcoding technology at the point of medication administration helps prevent

medication errors as it identifies the patient and ensures that the drug about to be administered is

the prescribed drug in the appropriate dose.

When it comes to administering medications, it is essential that for the nurse to

understand why their patient is prescribed a certain medication and the desired effect in relation

to the patient’s condition. The nurse should be familiar with the medication’s mechanism of

action, therapeutic effect, side effects, interactions, and contraindications. As always, use the

patient as a source for identifying errors if they are alert and oriented. If the patient does not

recognize the color of a pill or has questions about a certain medication, listen to their concerns

and use that opportunity to verify the medications that are being administered. To avoid wrong

dose errors, it is important to have a second person verify the dose when calculations are

necessary or when drawing a dose into a syringe. During medication administration, if a dose

requires an unusually large number of units (more than 3) it should be an indication to stop and

double check the order and the product. If something does not look right, it is always prudent to

ask a colleague, pharmacist or provider. To prevent wrong route errors, it is essential to check

lines before administering intravenous medications and connection systems. For example, if a

pre-packaged medication does not have a Luer lock connector, it is probably not intended for IV

use. While there are specific ways to prevent each type of medication error from occurring,

limiting distractions, avoiding interruptions, and asking questions when unsure about something

are all essential to safely administering medications.

Impact on Students
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In the clinical setting, I worry that I will commit a medication error that has failed the

healthcare system’s series of checks and balances. As a student nurse, it is daunting to learn

about the expectations of a bedside nurse, and I feel that they are often rushed and trying to

complete all of their tasks. To prevent this, I plan to take my time and be thorough in

administering medications, looking up medication indications and doses beforehand, and

reaching out the provider if I have any questions or concerns. I believe it is essential to minimize

distractions, avoid interruptions, and start over if I am interrupted to avoid inadvertently skipping

a step and introducing error.

Conclusion

Through identifying common medication errors, understanding their impact on patients

and families, and recognizing the steps that can be taken to prevent them from happening in the

future, I feel more confident in my ability to safely administer medications as a student nurse.

Administering medications is an important part of bedside nursing, and it is essential that nurses

have the confidence to detect and correct medication errors. By learning about common

medication errors, witnessing how nurses administer medications in the clinical setting, and

having the opportunity to pass medications myself, I understand that there are hundreds of ways

that medication errors can occur. My goal in clinical practice is to be acutely aware of situations

that place patients at risk and to prevent errors from reaching them. Ultimately, it is essential to

recognize that as long as there are humans in the process, errors will occur, but that patient safety

must always be the top priority in clinical practice

References

Chen, Y., Wu, X., Huang, Z., Lin, W., Li, Y., Yang, J., & Li, J. (2019). Evaluation of a medication

error monitoring system to reduce the incidence of medication errors in a clinical

setting. Research in Social and Administrative Pharmacy.

Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Review article: Prevalence

of computerized physician order entry systems–related medication prescription errors: A

systematic review. International Journal of Medical Informatics, 112–122.

Rishoej, R. M., Almarsdottir, A. B., Christesen, H. T., Hallas, J., & Kjeldsen, L. J. (2017).

Medication errors in pediatric inpatients: a study based on a national mandatory reporting

system. European Journal of Pediatrics, (12), 1697.