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Running head: Medication Safety

Medication Safety
Amber Morin
University of South Florida

Medication Safety
The prevalence of medication errors is astounding. On average, a hospital patient in the
US is exposed to one medication error per day; this ultimately leads to over 7,000 deaths per year
in this country alone (Flynn, Liang, Dickson, Xie, & Suh, 2012). The healthcare system as a
whole is continually trying to reduce this preventable problem. However, nurses are at the
forefront of this issue. In fact, research has shown that out of all healthcare employees nurses are
the most likely to identify and fix a medication error before these errors reach the patient (Flynn
et al., 2012). Since nurses play a part in both making errors and preventing them, it only makes
sense that nurses need to learn and understand the skills to prevent medication errors. While
there have been many strides to prevent medication errors, there still is work to be done. To still
have such a high prevalence of medication errors, even after all the work that has been put in
shows that there is still change that needs to ensue in order to minimize this devastating problem.
Leading Causes of Medication Errors

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A medication error can occur at any stage of the process. There are so many people and
steps that a medication must go through in order to reach the patient, but we still have an
extremely high prevalence of medication errors. The top medication errors are:
prescription errors, such as wrong drug, dose, or form, interpretation errors, such as
misinterpretation of abbreviation, handwritten and spoken prescriptions, preparation
errors, such as calculation and dispensing errors, and administration errors, such as wrong
dose or wrong time to give or not give a medication. (Tzeng, Yin, & Schneider, 2013).
Another leading cause of medication errors is poor nursing environments. Nursing practice
environments are significantly associated with nurses error interception practices (Flynn et al.,
2012). Furthermore, cognitive errors may be involved in errors in human behavior, such as
medication errors (Tzeng et al., 2013). These cognitive errors happen due to deficient
knowledge. Therefore, changes in nursing education may need to be done to help prevent
medication errors.
The 6 Rights of Medication Safety
The six rights of medication safety is an invaluable tool for nurses to use in order to
prevent medication errors. If done correctly, the six rights should dramatically reduce medication
errors. To begin, the first right is right patient. Nurses need to make sure they are giving the
medication to the correct patient due to the harmful effects it could have for the patient you were
supposed to give the medication to and the patient you accidently gave the medication to. This
right can be implemented by matching up the patients name in the MAR, with the patients
wristband, and with the patient stating their name. The second right is right medication. Nurses
need to make sure they are giving the medication to the patient. Nurses also need to make sure
they are giving the right dose of the medication. Giving too small or too large of a dose could
cause a medication not to work, or worse could severely hurt the patient. Also, nurses need to
make sure there are giving the medication through the right route. Giving a medication IV push

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when it was supposed to be IV piggyback would be disastrous. The fifth right is giving the
medication at the right time. Most medications are given at specific times of the day.
Furthermore, some medications have to be given at an exact same time due to dangerous side
effects if this is not followed. The final right is right documentation. If a nurse did not document
that they gave a medication, the next nurse will think that the patient never received the
medication. This could result in the patient receiving the medication for a second time, which
could clearly be very dangerous.
Supportive Nursing Environments
Good nursing environments are significantly associated with nurses more frequent
engagement in error interception practices (Flynn et al., 2012). Good nursing environments can
be made by encouraging collaborative teamwork, increasing opportunities for nurses to
participate in hospital and unit decisions, offering education opportunities, and retaining nurse
administrators that are accessible, listen to concerns, and expect high standards from the staff
(Flynn et al., 2012).
Building Clinical Cognition
Clinical cognition can be learned and taught by using a care-based approach with a
coached discussion to teach reasoning (Tzeng et al., 2012). Rather than waiting for the mistake
to happen in order to learn from it, clinical cognition can be learned through simulation-based
learning approaches with debriefing (Tzeng et al, 2012). This clinical cognition makes for more
experienced nurses; units with more experienced nurses had lower medication errors (Tzeng et
al., 2012).
Conclusion
Medication errors continue to be a major problem in the healthcare field. The most
common medication errors could be prevented by using the 6 rights of medication
administration. Moreover, supportive nursing environments and higher education of nurses were
associated with less medication errors. As a nursing student, I have been implementing the 6

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rights every time I give a medication. I also look up the drugs in order to know what
assessments, side effects, and interactions that I need to look out for. These are both skills I need
to continue to implement throughout my nursing practice in order to prevent myself from making
a medication error. Also, I will soon have the opportunity to participate in simulation. This will
give me a patient scenario that will allow me to learn from any mistakes made without any true
repercussions such as hurting a patient. With these tools, I will be less likely to make a
medication error.

References
Flynn, L., Liang, Y., Dickson, G.L., Xie, M., & Suh, D. (2012). Nurses Practice Environments,
Error Interception Practices, and Inpatient Medication Errors. Journal of Nursing
Scholarship, 44(2), 180-186. doi: 10.1111/j.1547-5069.2012.01443.x
Tzeng, H., Yin, C., & Schneider, T.E. (2013). Medication Error-Related Issues in Nursing
Practice. Medsurg Nursing, 22(1), 13-16.