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Medication Errors
Sarah Gift
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.
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
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
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
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
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
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.
material (i.e. similar names, similar packaging), or environmental sources (i.e. medications next
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.
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
and avoiding medication errors. The six rights include verifying the right patient, right drug,
MEDICATION ERRORS 5
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
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
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
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
Conclusion
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
References
Chen, Y., Wu, X., Huang, Z., Lin, W., Li, Y., Yang, J., & Li, J. (2019). Evaluation of a medication
Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Review article: Prevalence
Rishoej, R. M., Almarsdottir, A. B., Christesen, H. T., Hallas, J., & Kjeldsen, L. J. (2017).