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Kierra Wiley

Professor Dean Leonard

English 1201.509

05 July 2019

Medication Administration Errors

Every year in the United States, 1.5 million people on average, are injured from

medication errors (American Nurse Today). "A medication error is any preventable event that

may cause or lead to inappropriate medication use or patient harm while the medication is in the

control of the healthcare professional, patient, or consumer. Such events may be related to

professional practice, healthcare products, procedures, and systems, including prescribing, order

communication, product labeling, packaging, and nomenclature, compounding, dispensing,

distribution, administration, education, monitoring, and use" (Ragau, Sharon, et al.). Medication

administration errors are a significant problem affecting millions of people each year due to

unsafe nurse to patient ratios, hours worked in healthcare, lack of communication, and similarly

labeled or pronounced medications.

For some, it seems complicated to comprehend the number of medical errors that lead to

injury or death each year. How are nearly 1.5 million people harmed annually due to medication

errors that healthcare professionals have extensive training for? Medication errors that can be

prevented in many cases? The reality is that nurses, doctors and other healthcare team members

are all human who are capable of making unintentional mistakes. Even the most trained,

respected and highly paid healthcare professionals make life-changing errors. So what causes

these mistakes? Lack of attention to detail when working with patients? Not enough training on
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specific subjects relating to medication in school programs? Are healthcare professionals not

getting enough clinical hours before they are expected to practice on their own free will? What is

the cause of these medication errors and how can changes be made to improve safety in

healthcare?

According to Medication Errors and Adverse Drug Events, an error that takes place

between the time the drug is prescribed to administration, resulting from either omission or

commission is a medication error. Next, an adverse drug event (or commonly known as ADE) is

harm that comes from a medication given to a patient. An example of an ADE could be death

resulting from a drug miscalculation. Adverse drug events are sometimes preventable, but not

always. Studies done determined that half of ADE's are preventable. When a patient correctly

receives a drug but experiences side effects, this is an adverse drug event that could not have

necessarily been prevented. Side effects are common, and it is hard to estimate when a patient

will or will not experience drug side effects.

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Fig. 1. Medication Mistakes (“Medication Errors Kill 7,000 Each Year.”)

The process of medication administration is one that involves the prescription for the

drug, dispension, and then administration to the patient. After administration, the patient is

monitored to see how they respond to the drug. Errors can occur at any time - from prescription

to administration and sometimes are intercepted by members of the healthcare team. 26-32% of

medication errors are administration errors. Most medication administrations are performed by

nurses (American Nurse Today).

Reports done in the 1990s determined that most medication errors take place in the

administration process, which is the last and most crucial step in the medication pathway, as it

directly affects the patient. When giving a single intravenous medication, another study found

that there was a 73% chance that there would be at least one error made during the

administration process. The most common reason for the errors was determined to be wrong

timing, meaning the IV drug was most likely given before it was due (Medication Administration

Errors). Not to say that administering medication via the intravenous route is an easy task, but

there should not be a high risk at 73% that an error will be made. Another common area of

medication administration errors is with pediatric patients. Children can be more challenging to

do drug calculations for because dosages are not just based on weight, but also their body surface

area. Children have different proportions for weight and height than adults do, which can result

in errors being made during the process of prescribing and administering medications

(Medication Administration Errors).

In 2001, a little girl named Josie King was admitted to Johns Hopkins Hospital for

injuries she sustained in a hot bathtub. The 18-month-old was treated for her burns and began to

heal quickly. Less than a month after being admitted, Josie died just days before she was
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scheduled to be discharged. Josie's nurse had administered a narcotic even though the order for

the drug had been discontinued following an adverse reaction. Immediately after the narcotic was

administered, Josie went into cardiac arrest. She spent her remaining time in the ICU before she

passed away (HealthLeaders).

There were tell-tale signs that Josie was not herself during her stay in the hospital. Her

mother repeatedly told the nurses and doctors that Josie seemed lethargic and even dehydrated.

Each time Josie saw liquids or took a bath, she would cry and suck on her washcloths profusely.

These were not normal or healthy behaviors for Josie. Not only were all of these signs ignored,

but a critical order regarding her medication was not communicated properly. Unfortunately,

Josie suffered a life-threating adverse reaction to a narcotic used for pain management. Because

of the reaction she suffered, her doctors decided the safest thing to do was discontinue the

medication order. If this order had been communicated and documented the correct way, Josie’s

nurse would have known not to give her the narcotic. In 2010, the hospital claimed that Josie's

death was a result of septic shock from a hospital-acquired infection (Nitkin, Karen, et al.).

Regardless of the exact cause, Josie's death could have been prevented had her doctors and

nurses communicated and worked together as a team.

Another story that focuses on medication administration errors is one that is current and

took place in Columbus, Ohio at Mount Carmel West Hospital. In a span of three years, from

2015 to 2018, over 27 patients had potentially been given lethal doses of fentanyl before they

died. A “normal” dose for fentanyl is approximately 100 micrograms depending on age, weight

and use for the drug. Many patients of Dr. Husel were given over 1000 micrograms, a fatal dose

ten-times over the normal range. Dr. William Husel, along with over twenty faculty members,

are being investigated following the patient deaths (Erik Ortiz).

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On average, each hospital has a system for how medications are ordered, sent out,

administered and documented. According to Erik Ortiz, in a hospital setting, medications are

ordered in the following way: the doctor prescribes the medication through an electronic system

(most facilities no longer physically write medication orders on paper, as a way to prevent

errors). Next, a pharmacist receives the order and either approves or disapproves the prescription

based on patient information, medications the patient is currently taking and of course, dosage.

Once the prescription is approved, the medication is then sent to the floor or unit requested

where a nurse can obtain it. The nurse receives the drug and begins preparing it for

administration. During this time, the nurse confirms the drug, dosage and patient information

with the prescription several times to prevent errors. If the nurse at any point feels that the dose

is incorrect or has a question about the drug, they are able to contact the doctor before

administering it to the patient (Erik Ortiz).

In this situation, the nurses and pharmacists should have checked the normal dosage

ranges for fentanyl before administering the medication. Had they seen that the medication order

was ten-times over the normal dosage range, patient’s lives may have been saved. Ohio is not a

state that allows assisted suicide by physician. Furthermore, it should not have taken three years

before Dr. Husel's actions began to be questioned and investigated. Patients continued to die

under the careless decisions made by Dr. Husel to administer lethal doses of fentanyl and other

similar painkillers.

The key elements of medication use are drug information, drug packaging, nomenclature

and labeling, patient information, adequate communication, environmental factors,

standardization, patient education, drug device acquisition, use, and monitoring, and distribution,

medication storage, quality processes and risk management, stock, and staff education and
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competency (American Nurse Today). First and foremost, patient information is crucial because

what is the point in giving the correct drug, dosage and form to the wrong patient? Before

administering a drug, the nurse should always check the ID bracelet of the patient and the drug

order to confirm both sets of information are correct and matching. Barcoding systems are now

being implemented in many hospitals and other medical facilities as a way to prevent medication

errors in patients. Studies on barcode medication administration technology have found that there

has been a 41% reduction in errors, a 27% decrease in drug timing errors (giving a patient their

medication too soon) and a 51% reduction in potential ADE's (adverse drug events) which is

astonishing (Medication Administration Errors). If all inpatient medical facilities used barcoding

technology, medication errors could be reduced drastically.

Next, as stated previously, drug information has to be correct. This includes the right

drug (many drugs have similar spelling and pronunciation), the right dose, right route (oral, IV),

right time and right documentation. Medication orders should be checked multiple times as they

are being prepared and before given to the patient. Unfortunately, it is easy for nurses to become

distracted while preparing a medication order. Taking the extra time and steps ensures the patient

is given the correct drug ordered and promotes safety. The Joint Commission, which is an

organization that focuses on safety measures in healthcare and implements changes in order to

prevent future errors, wanted to minimize interruptions nurses face in the workplace in order to

reduce medication errors (Medication Administration Errors). New safety policies are being

implemented in many hospitals and similar healthcare facilities that require drug calculations be

done in the medication room (which is enclosed) with only one nurse permitted in the room at a

time (unless there is an emergency). This policy change was designed to minimize distractions

and interruptions the nurse may face to reduce medication errors.

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Another key element of medication use is adequate communication. This is seen when

referring back to Josie King’s story. Josie’s mom repeatedly told her daughter’s nurse that she

was not supposed to be given any more narcotics following the adverse reaction. Even though

the nurse heard this, she did not confirm the mother's statements with Josie's doctor. The nurse

administered the narcotic, which led to Josie's cardiac arrest. Nursing (and medicine in general)

can become complicated, confusing and even overwhelming at times. When Josie’s mom made

the statements regarding medication to her daughter’s nurse, the nurse should have responded

with precautionary measures by contacting the primary healthcare provider. When responsible

for others’ lives, it’s better to be safe rather than sorry. Had there been proper communication

and documentation between hospital team members, Josie King may not have passed away

during her hospital stay at Johns Hopkins. Effective communication in healthcare is essential in

order to keep patients, families and the staff safe.

The last key element of medication use discussed in this paper will be drug labeling and

packaging. There are hundreds of thousands of different drugs on the market today in healthcare.

Most drugs have both a generic and trade name, as well as similar packaging depending on the

manufacturer. Because there are many drugs available with similar packaging, spelling and

pronunciations, it can be easy to switch up medications unintentionally. An example of this is an

event that took place in 2007.

Famous Hollywood actor, Dennis Quaid, and his then-wife, Kimberly Quaid, welcomed

twins in November 2007. Two weeks after they were born, the twins were admitted to Cedars-

Sinai hospital in Los Angeles to treat a staph infection. One night while the twins were in the

hospital, Quaid called to check in on them. The nurse responded that the twins were doing fine,

but in reality, they were not. Earlier that day, the nurse had accidentally overdosed the twins on a
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common blood-thinning agent, heparin, by over 1,000 times the recommended dose. Thomas

Boone and Zoe Grace's intravenous sites began seeping blood, which led the nurses to recognize

that there was something very wrong. Even though the incident had happened two hours earlier,

Dennis Quaid was not informed of the situation when he called. All medical decisions were

made without Quaid's knowledge or input; he would not learn of the incident until the following

morning (Charles Ornstein).

It came to light after an investigation that the heparin given to the twins was the adult

dose instead of the pediatric dose. The adult bottle of heparin had accidentally been placed into

the Pyxis where the twins’ nurse obtained it. This unintentional and almost fatal action happened

as a result of the two bottles of heparin (adult and pediatric) looking nearly identical. In 2008, the

Quaid’s, filed a lawsuit with the manufacturer of the heparin, Baxter Healthcare Corp. stating

that the adult and pediatric bottles of heparin had labels that were too similar and were the cause

of the error. The drug's manufacturer responded that the error took place from improper use, not

the drug or labeling. Fortunately, the twins made a full recovery after spending eleven days in the

NICU (neonatal intensive care unit) (Charles Ornstein).

According to American Nurse Today, healthcare organizations should be aware of and

alert employees of medications on the Joint Commission's "high-alert" drug list. This list

includes drug names that have similar spelling, pronunciation and labeling so that nurses and

other healthcare team members can be aware of these similarities and double-check orders being

prepared. In fact, in a span of three years, from 2003-2006, over 25,000 medication errors were

reported due to drugs that had similar spelling and pronunciation (American Nurse Today). The

Quaid's twins were not the only victims of the heparin mix-ups. In another hospital, three infants

died because of the similarly labeled bottles of heparin. Over time, more lawsuits were filed
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which eventually led Baxter Healthcare to change the labels with different font sizes and color to

distinguish the difference between pediatric and adult heparin bottles (Charles Ornstein).

Not only do medication errors commonly take place due to ineffective communication,

documentation or similarly labeled and pronounced drugs, but they can also occur as a result of

an unsafe nurse to patient ratio and work overload. Studies have shown that medication errors are

frequently the result of stress and fatigue in the workplace. Stress and fatigue, as well as work

overload, creates an unhealthy work environment which can result in more medication errors

(Mieiro, Debora Bessa, et al.). Having unsafe nurse to patient ratios creates a stressful and unsafe

environment for both the nurse and the patients. Nurses have to pay attention to nearly every

detail with each patient during a shift. The more patients a nurse is responsible for, the easier it is

to neglect critical tasks or make mistakes as well as become overwhelmed. Nurses generally

work three twelve-hour shifts each week, but these hours can vary based on the needs of the

hospital and if there is a shortage of staff. The demand and need for nurses are at an all-time high

today, which unfortunately leads to short-staffed hospitals, mandatory overtime and burnout

from working at the bedside.

Because nurses and other healthcare professionals commonly become overwhelmed and

stressed at work, a study was done on a system called the Halt Model to see if it could possibly

help employees manage stress and reduce medication errors in the workplace. The Halt Model is

a system used to evaluate how someone is feeling and if their feelings can affect their job. There

are four categories to the Halt Model: Hunger, Anger, Late, Lonely and Tired. With each

category, a question is asked to evaluate the emotions of that person (Ragau, Sharon, et al.).

Most people are not as efficient with their job when they are hungry, angry, late, lonely and

especially tired.
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After implementing the HALT project, hospitals and its’ employees had found it to be

very positive and educational. In fact, many members of nursing teams found that they had a

better understanding of stress in the workplace and signs of stress to look for in themselves and

colleagues (Ragau, Sharon, et al.). After identifying signs of stress or fatigue, nursing members

learned to ask important questions such as, ‘Do you need to HALT?’. If the response is yes,

taking a few minutes to take a deep breath, drink some water, and even eat a small snack is a

great way to reset the mind and center oneself before working with patients again (Ragau,

Sharon, et al.). Nursing is about caring for others, and it is hard to take care of someone else

when you are not in the right place mentally and physically.

There are endless causes of medication errors in healthcare. Luckily, there are many ways

that nurses and other healthcare members can promote safety when caring for patients. First,

regularly looking over the Joint Commission’s list of high-alert drugs and “do not use”

abbreviations can be a great way to prevent errors, just by being aware of common mistakes. For

example, the abbreviation ‘IU’ to describe international units, is no longer being used or

accepted because when it is written, it can be mistaken as ‘IV’ or ‘10’. Merely writing out

‘international units’ ensures that there will be no confusion. Next, having a colleague double-

check a dosage calculation for a high-alert drug can be a great way to make sure math is done

correctly, even for the most experienced nurses. Lastly, the Joint Commission states that leading

zeros can prevent misinterpretation of written medication orders (American Nurse Today). For

example, writing 0.5 mg with the leading zero prevents the misinterpretation of the dose actually

being 5 mg had it been written as .5 mg. Leading zeros are significantly important when writing

out a medication order.

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In conclusion, medication administration errors are a significant problem affecting

millions of people each year due to many reasons. Some of the most relevant causes of these

errors include unsafe nurse to patient ratios, hours worked in healthcare, lack of communication

and similarly labeled or pronounced medications. Knowing these causes of medication errors can

initiate policy changes and increase training on the subject. Understanding standards for safety,

mental health and causes of these medication errors can prevent future errors from occurring.

Changes need to be made in order to promote safety in healthcare facilities. If every hospital and

similar healthcare facility had specific training for medication errors, the statistic that 1.5 million

people are affected annually could be significantly decreased.

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Works Cited

HealthLeaders. “Josie's Story Teaches Hospitals How to Become Safer.” Josie's Story Teaches

Hospitals How to Become Safer | HealthLeaders Media, 3 Sept. 2009,

www.healthleadersmedia.com/clinical-care/josies-story-teaches-hospitals-how-become-

safer.

“Medication Administration Errors.” PSNet, psnet.ahrq.gov/primers/primer/47/Medication-

Administration-Errors.

“Medication Errors and Adverse Drug Events.” PSNet,

psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events.

“Medication Errors: Best Practices.” American Nurse Today, 22 Sept. 2017,

www.americannursetoday.com/medication-errors-best-practices/.

“Medication Errors Kill 7,000 Each Year.” PersonalInjury.com,

www.personalinjury.com/blog/video-medication-errors-kill-7000-each-year.

Mieiro, Debora Bessa, et al, “Strategies to Minimize Medication Errors in Emergency Units: an

Integrative Review.” Revista Brasileira De Enfermagem, vol. 72, no. suppl 1, 17 May

2019, pp. 307–314., doi:10.1590/0034-7167-2017-0658.

Nitkin, Karen, et al, “No Room for Error.” No Room for Error, 8 Jan. 2016,

www.hopkinsmedicine.org/news/articles/no-room-for-error.

Ornstein, Charles. “Quaids Recall Twins' Drug Overdose.” Los Angeles Times, Los Angeles

Times, 15 Jan. 2008, www.latimes.com/local/la-me-quaid15jan15-story.html.

Ortiz, Erik. “How Did a Doctor Allegedly Order Fatal Doses of Painkillers Connected to 28

Deaths?” NBCNews.com, NBCUniversal News Group, 26 Jan. 2019,

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www.nbcnews.com/news/us-news/ohio-physician-allegedly-ordered-28-people-

potentially-fatal-doses-opioid-n962516.

Ragau, Sharon, et al, “Using the HALT Model in an Exploratory Quality Improvement Initiative

to Reduce Medication Errors.” British Journal of Nursing, vol. 27, no. 22, 13 Dec. 2018,

pp. 1330–1335., doi:10.12968/bjon.2018.27.22.1330.