How to

Prevent
Medication
Related
Injuries

Policy Brief
Danielle
Many reason exist for making mistakes in
administering medication to our patients:
Fatigue
Personal Factors
Poor Communication between staff
members
Critical assumptions about the
medication being given
Personal distraction before
administration of the medication
There have been many policies put in place already to
help prevent medication errors. Even thought nurses are

aware medication errors exist it still remains one of the

highest-ranking preventable injuries.
Fatigue can occur when working more then 12.5 hours,
increased overtime or working more then 40 hours.
Most medication errors result from Fatigue.
123 respondents reported :

Near misses

Self Reported
Witnessed

The near miss events would be realizing that you were

giving the wrong medicine. These could be from
Transcription errors to personal factors.
We as nurses really need to rely on the systems that are
put in place for us to use to help prevent medication
errors. Nurses should clarify orders if there is any
questions, share information between doctors and
nurses, never leave while administering a medication. A

nurse can ask for help, clarification, and always be an

advocate for your patient.
Recommendations to prevent medication errors:
Use the 5 Rights Model
o Right patient
o Right drug
o Right dose
o Right route
o Right time
Use the STAR MODEL
o Stop
o Think
o Act
o Review
Visual Timer for intravenous pushes
No interruption Zone when a nurse is able to give
uninterrupted time to a patient.
Speak your directions for medication out loud
Reminder Signage
o On an IV pole
o Above a nurse server
o Above patient bed
o On a phone
Along with the wonderful systems that are already in
place to prevent medication errors, I would propose ways
to help prevent these errors would be to scan our
medication and patients ID band before administrating

the medication. I know that some hospitals already this

in place but it needs to become a Standardized practice
throughout all medical facilities. A substantial body of
evidence from international literature points to the risks
posed by medication errors and the resulting
preventable adverse drug effect. In the USA, medication
errors are estimated to harm at least 1.5 Million
patients per year(Agrawal,2009). Barcoding medication
administration system produced 54-87% reduction in
error during administration of medication (Agrawal,
2009).
Conclusion
Many systems are in place to prevent medication errors,
but we are still working against human mistakes. Nurses
can experience errors at any point in their career for
many reasons, but with the help of technology we have
access to electronic bar code scanning. This is proven to
help reduce errors throughout the world, but if it is not
implicated the amount of errors will continue to be a
raising problem. Medication errors are the single most
preventable injury in the medical field. It is our
responsibly to do anything it takes to reduce them.

Reference
Agrawal, A. (2009) Medication errors: prevention using
information technology systems. Retrieved from
www. Ncbl.nlm.nih.gov/pmc/articles/pmc2723209/
Federuco, F. (2014) The five rights of medication
administration, Institute for healthcare
improvement. Retrieved from
Http://www.ihi.org/resources/pages/improvementsto
ries/
Phillips,S.A, & Moffett,C. (2014). The implication of
nurse fatigue. Missouri state board of nursing
newsletter, 16(1), 8-10.
Speroni, KG. (2014) What causes near misses and how
are the mitigated? Plast Surg Nurs 2014 Julsep;34(3):114-9