Common Medication Errors

CommonMedicationErrorsandNursingInterventions
TiffanyTran
UniversityofSouthFlorida
NUR3215L
EdithaCustodio,MSN
October2,2016

Common Medication Errors

Theoccurrenceofmedicationerrorsisoneoftheleadingcausesofpatientdeaths
intheUnitedStates,claimingthelivesofatleast7,000hospitalpatientsperyear(Flynn,
Liang,Dickson,Xie,&Suh,2012).Medicationerrorsincludeadministeringmedications
tothewrongpatients,atthewrongtimes,inwrongdoses,viaincorrectroutes,andthe
like.Thispaperhighlightsonetypeofmedicationerrorthatcommonlyoccursinpractice
administeringtheincorrectdoseofmedication.Additionally,thispaperwilldiscuss
nursinginterventionsthatcouldbetakentopreventthiserror.Asnursesareonthe
forefrontofpatientcare,theyarethemosteffectiveandconsistentbarriersagainst
medicationerrorsreachingpatients(Flynnetal.,2012).
Everypatientisentitledtothesixrightsofmedicationadministration1)Right
patient,2)Rightdrug,3)Rightdose,4)Rightroute,5)Righttimeand6)Right
documentation.Acommonviolationofpatientsrightsisadministeringthewrongdose
ofanindicatedmedication.Administrationofanincorrectdosecouldbeduetoseveral
differentfactors.Itispossiblethatthemedicationwasavailableinadifferentdosethan
anticipated,butthenursewasunintentionallyblindtothisdosagedifference(Keers,
Williams,Cooke,&Ashcroft,2013).Inaddition,itisfeasiblethateitherthenurse
selectedtheincorrectconcentrationwithoutrealizingoranincorrectconcentrationbottle
wasplaced(orreplaced)intheimproperdrawerinthemedicationdispenser(Keersetal.,
2013).Yetanotherconceivableexplanationcouldbethatthenurseutilizedtheincorrect
typeofsyringee.g.usingaregularortuberculinsyringe(ratherthananinsulinsyringe)
todrawupandadministerinsulin(Keersetal.,2013).Further,andperhapsleast
defensibly,thewrongdoseissometimesadministereddeliberatelybynurses(whomay

Common Medication Errors

feeltheprescribeddosewouldbeinadequate),andiscommonlyknownasanursing
dose(Keersetal.,2013).
Whileitistruethattoerrishuman,nursinginterventioniskeyinminimizing
medicationerrorsindosing.Firstly,itisparamountthatsurroundingdistractionsare
minimized,allowingnursestofocusonthetaskathand(Keersetal.,2013).Although
completeeliminationofdistractionsisimprobable,makingthemedicationdispenser
roomasquietaspossibleallowsnursestoconcentratewhiledispensingandpreparing
medications.Moreover,whileexternaldistractionsmaybeoutofthenursescontrol
patientload,understaffing,patientacuity,disruptivephonecallsorinteractionswith
others(visitorsandcoworkersalike)thereareinternalfactorsthateachnursecanutilize
asasafeguardagainstadministeringthewrongdose(Keersetal.,2013).Nursescan
ensurethattheycheckthemedicationthreeseparatetimes.Theinitialcheckoccursatthe
medicationdispenser,whenthenursechecksthemedicationlistedinthedispenser
againstthepatientsmedicationadministrationrecord(MAR).Thesecondcheck
transpiresoncethemedicationhasbeendispensedand,perhaps,isbeingprepared
comparingtheMARtothemedicationpackaging.Thethird,andfinal,checkhappens
insidethepatientsroom,matchingthepatientswristband,MAR,andthemedication.
Notably,thesecheckpointsshouldbeengagedtointerceptavarietyofmedicationerrors,
notjusttheincorrectdosage.
Mygreatestpersonalfear,regardingmedicationadministration,isthatIwill
administeramedicationtothewrongpatient.Workingasacaretechnicianinahospital,I
havewitnessedhoweasyitistobecomedistractedbythemanytasksathand.Working

Common Medication Errors

ondifferentunits,Iwouldsometimesfindmyselfwalkingintothewrongroomtogivea
patientasnackbecausetheroomswereinslightlydifferentplaces(e.g.Room34was
whereRoom32isontheotherfloor).Similarly,therewouldbetimeswhenacoworker
wouldtellmetheincorrectroomwhenaskingmetobringsuppliestoapatient.
Furthermore,thereweretimeswhenapatientwouldbetransferredandreplacedby
anotherpatient,withoutinformingallofthepatientshealthcareteam.Inanyofthese
occasions,itwouldhavebeenpossibletoadministermedicationtothewrongpatient.I
havedecidedthatthebestwaytopreventmyselffromadministeringmedicationtothe
incorrectpatientistodevelopandfollowthesameadministrationsystemeachtime,no
matterthecircumstances.Thissystemwouldincludeemployingthethreecheckpoints
underscoredabove,aswellasaskingthepatienttoverbalizehisnameanddateofbirth
ratherthanaskinghimtomerelyconfirmmyverbalizationofhisidentifiers.Thelatter
precautionisespeciallyimportantwhenworkingwithmentalhealth,elderly,other
languagespeakingorconfusedpatients.Thesepopulationscouldpotentiallyagree
withoutknowingtowhattheyareagreeing.Ifthepatientcannotverbalizehisname,I
willcheckhisnameanddateofbirthlistedonthewristbandagainsttheMAR.
Ultimately,whilethesafeadministrationofmedicationiseveryones
responsibility,nurseshaveauniqueabilitytoadvocatefortheirpatients(Flynnetal.,
2012).Bedsidenurseshavedirectandintimateaccesstopatients.Theycanemploytheir
knowledgeofmedicationsandofthepatientsthemselvesinordertodefendagainstthe
incorrectdosage,route,ormedication.Inadditiontobeingthefrontline,bedsidenurses
couldbeseenasthelastbarricadebetweenapatientandamedicationerror(Flynnetal.,

Common Medication Errors

2012).Thereby,inbeingvigilant,nursescanthwartmedicationerrorsandreducethe
numberofadversepatientoutcomes,includingdeaths,eachyear(Flynnetal.,2012).

References
Flynn,L.,Liang,Y.,Dickson,G.L.,Xie,M.,&Suh,D.C.(2012).Nursespractice
environments,errorinterceptionpractices,andinpatientmedicationerrors.
Journalofnursingscholarship,44(2),180186.doi:10.1111/j.1547
5069.2012.01443.x
Keers,R.N.,Williams,S.D.,Cooke,J.,&Ashcroft,D.M.(2013).Causesofmedication
administrationerrorsinhospitals:asystematicreviewofquantitativeand
qualitativeevidence.Drugsafety,36(11),10451067.doi:10.1007/s40264013
00902.