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Running head: MEDICATION ERRORS

Medication Errors
Christina Weyant, SBN, MPM
NUR3215L

MEDICATION ERRORS
Medication errors present a significant problem in the health care setting today. It is
estimated that between 44,000 and 98,000 people die each year as a result of mistakes made by
medical personnel, and many of those deaths can be attributed to medication errors (Pham, Story,
Hicks, Shore, Morlock, Cheung & Pronovost, 2011). Errors in medication administration are
incredibly common, with mistakes being reported in as high as 25 percent of medications
administrations (Westbrook, Woods, Rob, Dunsmuir & Day, 2010). Medication errors can result
in immense pain and suffering for patients, and their families, and in many cases they are
completely avoidable.
The majority of the medication errors that occur are perpetrated by nurses, and they
happen during the medication administration process. According to one study of emergency
department medication errors, 54 percent of errors were made by nurses (Pham et al, 2011). One
of the largest factors contributing to medication errors is interruptions. Research has found that
when interruptions occur during the drug preparation or administration process, errors are
substantially more likely to occur, and the risk increases with the number of interruptions during
the process (Westbrook et al., 2010). It was found that the risk for a medication error can even
double when there are four or more interruptions present during medication administration
(Westbrook et al., 2010). Interruptions and distractions may lead to a breakdown in following
procedural guidelines which are set in place to help eliminate unnecessary medication errors.
Doing away with interruptions completely is not realistic in the field of healthcare, but
there are some things that nurses can do to help reduce the number or distractions during the
medication prep, and administration process. One intervention is the implementation of no
talking policies in medication rooms. This could reduce things such as casual conversations
while nurses are pulling and preparing medications, and lead to a reduction in unnecessary

MEDICATION ERRORS
distractions. Nurses may also want to avoid asking one another for help during the medication
administration phase unless it is an urgent situation. If the situation does not require immediate
attention, the nurse may want to wait until after medications are administered and documented to
approach their fellow nurse (Westbrook et al., 2010). Finally, because urgent situations are going
to happen in healthcare, and some amount of distractions are inevitable, it is important that
nurses recheck the five rights of medication administration once the distraction has subsided. The
five rights include right patient, right medication, right dose, right route, and right time (Adams
&Holland, 2014). In addition nurses can check a sixth right for right documentation. Reassessing
these rights can help ensure that a momentary distraction does not result in a potentially
dangerous medication error.
The medical error that I am most afraid of making is allowing interruptions to distract me
from what I am doing, and lead me to overlook something. I know that as long as I follow the six
rights I should not have any medication errors, however, if I am very distracted or feeling rushed
I may miss something, and that could be very detrimental. I also know that I occasionally get
flustered when there are several different things going on, and I am more prone to making
mistakes during those situations. In order to reduce my own risk of making an error I will have to
realize when I am distracted from my task, and take a second to refocus on what I am doing.
From that point I can diligently assess the six rights, as well as any relevant lab values or
potential problems. Another thing I can do is if another staff member is distracting me I can
politely tell them that I am in the middle of something important, and I can talk to them or help
them after. Finally, I will have to understand that it is possible that I will get interrupted multiple
times, and it will be important for me to remember that I should reassess everything before

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administering the drug no matter how many interruptions I have had, and that I should never just
go ahead and give a drug just because I am feeling rushed.
In conclusion, mediation errors are a substantial problem in the healthcare setting, and
they can lead to poor outcomes, and unnecessary harm to patients. Most medication errors occur
during the medication administration process, and major factors contributing to errors are
interruptions and distractions. These errors can be reduced by implementing policies to help
reduce distractions during the medication prep and administration phases, along with reassessing
the five rights plus right documentation after the interruption has ceased.

References

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Adams, M., & Holland, L. (2014). Principles of Drug Administration. In Pharmacology for
nurses: A pathophysiologic approach (4th ed., p. 20). Upper Saddle River, N.J.: Pearson
Education
Pham, J., Story, J., Hicks, R., Shore, A., Morlock, L., Cheung, D., Pronovost, P. (2011).
National Study On The Frequency, Types, Causes, And Consequences Of Voluntarily
Reported Emergency Department Medication Errors. Journal of Emergency Medicine,
40(5), 485-492.
Westbrook, J., Woods, A., Rob, M., Dunsmuir, W., & Day, R. (2010). Association Of
Interruptions With An Increased Risk And Severity Of Medication Administration Errors.
Archives of Internal Medicine, 170(8), 683-690.