Running head: MEDICATION ERRORS

Medication Errors
Katherine Rivas
University of South Florida

MEDICATION ERRORS

Throughout history we have seen the medical field evolve in numerous ways. We have
seen differences in care, new medication, up-to-the-minute medical technology, and even
different models in the patient doctor relationship. However, one thing that still remains globally
despite of innovative technology and occurs every day is, medication errors. Unlike other fields,
in medicine a small error can have a huge impact in a persons life. Doctors, nurses and
pharmacists do not have the luxury to make a mistake because unlike a carpenter, once it is done
it cannot be reversed. According to Zimmerman in Medication Administration Errors in
Assisted Living: Scope, Characteristics, and the Importance of Staff Training, medication errors
occur in all kinds of nursing facilities and they are made by licensed practical nurses and
registered nurses as well. In this paper I will discuss a common error that occurs in hospitals and
clinics across the United States and the world, and thats giving the wrong dose. I will also
discuss interventions for this medication error, as well as which one I am most afraid to do.
If you enter any hospital in any country in the world, you will see that they are loud,
hectic and usually filled with people. For nurses especially it is very difficult to concentrate on a
single task for a given period of time because they tend to be pulled in different ways by patients,
doctors, families and other nurses. The task of giving medication is more intricate than it sounds.
A nurse should check the medication three times, check for allergies, check for the correct route
of administration, correct patient etc. The biggest problem is that nurses have so many
distractions while theyre administering medications that they wont notice when a mistake is
made until it is too late. The nurse will know a mistake has been made when the patient shows an
abnormal reaction right after a medication has been administered. In the article, it states that
when they were observing these nurses for a study, they noticed the main problem was
administering the wrong dose across the board. In the article they observed 4,957 drug
administrations and the wrong dose was given by registered nurses and licensed practical nurses.

MEDICATION ERRORS

The most common errors were made with medications that were given on a daily basis, The
errors of most concern involved administration of insulin, ipratropium, and warfarin, which
typically have a low therapeutic ratio or must be administered at relatively precise times
(Zimmerman et al., 2011). This is of great concern because these medications have specific times
that they need to be administered and are very potent, so if a wrong dose is given it can definitely
cause death.
To avoid medication errors it is vital to implement interventions that can help prevent
them before it is administered to a patient. These interventions need to begin before the
medication is introduced into the room with the patient. Some interventions need to be followed
by others that are involved in the patient care such as the pharmacists and the doctors. In the
article, Interventions to Reduce Medication Errors in Adult Intensive Care by Manias and
Williams, they explain that there are eight interventions that can help reduce medication errors,
Eight different types of interventions were identified: computerized physician order entry,
changes in work schedules, intravenous systems, modes of education, medication reconciliation ,
pharmacist involvement, protocols and guidelines and support systems for clinical decisionmaking (Manias et. al, 2012). All these interventions are essential to reduce errors because it
starts with the pharmacist by being specific in their instructions and cautious of using
abbreviations, and then it moves away from orders being hand written to computerized entries by
physicians. Changes in work schedule is important as well because there is a correlation between
medication mistakes and the nurse to patient ratio. If a nurse has too many patients on her shift
this can cause the nurse to make a mistake. Also long work hours can cause a nurse to be tired
and make a mistake however if her shift was shorter she could make critical decisions. Finally
one of the most significant interventions is education. Educating the nurse about new
medications and the importance of right dosage is essential when it comes to medications that are

MEDICATION ERRORS

strong and can cause a lot of harm. It is also important to educate the nurse about the importance
of checking and rechecking her medications before she administers them and to ask questions if
she doesnt understand an order. Different modes of education need to be applied because it
helps nurses who have different methods of learning to understand and learn the importance of
preventing these errors.
Out of all the errors a nurse can make when administering a medication, I am most afraid
of administering the wrong dose because it can be deadly if it is more than the patient should
receive. Its also more difficult to administer a medication to the wrong patient or at the wrong
time because of all the new computerized systems that we have to use before we administer.
However the wrong dose can occur at any time because of a mistake by the pharmacy, the doctor
or by the nurse if not they are not cautious enough. I plan to always perform the 6 rights of
medication in my mind as well as the 3 checks before I administer anything to a patient.
In conclusion medication errors happen every day in the United States and throughout the
world. Medication errors have cost many lives in the health care system and if interventions are
not applied they will continue to do so. When a patient comes to a hospital they place their lives
in our hands and it is our responsibility to be as safe as possible when we administer
medications. Administering a wrong dose can be deadly and therefore every nurse, pharmacist
and doctor should be educated on the importance of checking medications and asking questions
when they dont understand something. Low nurse to patient ratios can also help prevent these
errors so nurses have time to focus on their patients and can make critical decisions in a timely
manner. By reading these articles I learned ways to prevent myself and others from making this
fatal mistake.

MEDICATION ERRORS

References
Manias, E., Williams, A., & Liew, D. (2012). Interventions to reduce medication errors in adult
intensive care: a systematic review. British Journal of Clinical Pharmacology. Retrieved
October 2, 2014, from http://eds.a.ebscohost.com.ezproxy.lib.usf.edu/eds/pdfviewer
Zimmerman, S., Love, K., Sloane, P., Cohem, L., Reed, D., & Carder, P. (2011). Medication
Administration Errors in Assisted Living: Scope. Journal of the American Geriatrics
Society. Retrieved October 2, 2014, from
http://eds.a.ebscohost.com.ezproxy.lib.usf.edu/eds/pdfviewer