Medication Errors

www.AmericanNurseToday.com March 2010 American Nurse Today 23

A CRITICAL CARE NURSE tries tocatch up with her morning medica-tions after her patients conditionchanges and he requires severalprocedures. He is intubated, so shedecides to crush the pills and instillthem into his nasogastric (NG)tube. In her haste to give the al-ready-late medications, she fails tonotice the Do not crushwarningon the electronic medication ad-ministration record. She crushes anextended-release calcium channelblocker and administers it throughthe NG tube. An hour later, the pa-tients heart rate slows to asystole,and he dies...

A patient returns from surgery,anxious and in pain, with severalI.V. lines and an intracranial pres-sure (ICP) monitor in place.The I.V.tubing used in the operating roomdiffers from the tubing used in theintensive care unit (ICU). In herhaste, the ICU nurse prepares to in-ject morphine into the patients ICPdrain, which she has mistaken forthe central line. She stops just intime when she realizes shes aboutto make a serious mistake...

A physician writes an order forprimidone (Mysoline) for a 12-yearold boy with a seizure disorder.Mis-reading the physicians handwrit-ing, the pharmacist mistakenly fillsthe order with prednisone. For 4months, the boy receives pred-nisone along with his seizure med-ications, causing steroid-induceddiabetes.The diabetes goes unrecog-nized, and he dies from diabeticketoacidosis...

Medication errors like these canhappen in any healthcare setting.According to the landmark 2006 re-port Preventing Medication Errorsfrom the Institute of Medicine,these errors injure 1.5 million Amer-icans each year and cost $3.5 bil-lion in lost productivity, wages, andadditional medical expenses. (SeeSobering statistics.)

Medication administration is acomplex multistep process that en-compasses prescribing, transcribing,dispensing, and administering drugsand monitoring patient response.An error can happen at any step.Although many errors arise at theprescribing stage, some are inter-cepted by pharmacists, nurses, orother staff.

Administration errors account for26% to 32% of total medication er-rorsand nurses administer mostmedications. Unfortunately, mostadministration errors arent inter-cepted. Recent technological ad-vances have focused on reducingerrors during administration.

Ten key elements ofmedication useMany factors can lead to medicationerrors. The Institute for Safe Medica-tion Practices (ISMP) has identified10 key elements with the greatest in-fluence on medication use, notingthat weaknesses in these can lead tomedication errors. They are: patient information drug information adequate communication drug packaging, labeling, and

nomenclature medication storage, stock, stan-

dardization, and distribution drug device acquisition, use, and

monitoring environmental factors staff education and competency patient education quality processes and risk man-

agement.

Patient informationAccurate demographic information(the right patient) is the first ofthe five rights of medication ad-ministration. Required patient infor-mation includes name, age, birthdate, weight, allergies, diagnosis,current lab results, and vital signs.

Barcode scanning of the patientsarmband to confirm identity can re-duce medication errors related topatient information. But initially,barcode technology increases med-ication administration times, whichmay lead nursing staff to use poten-tially dangerous workarounds thatbypass this safety system. Also, thebarcode method isnt fail proof; the

Medication errors:Dont let them happen to youMistakes can occur in any setting, at any step of the drug

administration continuum. Heres how to prevent them.

By Pamela Anderson, MS, RN, APN-BC, CCRN, and Terri Townsend, MA, RN, CCRN, BC, CVN-II

LEARNING OBJECTIVES1. Identify the 10 key elements of

medication use.2. Describe the role of clinician

fatigue in medication errors.3. Discuss strategies to prevent

medication errors.

CE1.6 contact

hours

24 American Nurse Today Volume 5, Number 3 www.AmericanNurseToday.com

patients armband may be missingor may fail to scan, or the scannersbattery may fail.

Drug informationAccurate and current drug informa-tion must be readily available to allcaregivers. This information cancome from protocols, text refer-ences, order sets, computerizeddrug information systems, medica-tion administration records, and pa-tient profiles.

Adequate communicationMany medication errors stem frommiscommunication among physi-cians, pharmacists, and nurses.Communication barriers should beeliminated and drug informationshould always be verified. One wayto promote effective communicationamong team members is to use theSBAR method (situation, back-ground, assessment, and recom-mendations).

Poor communication accounts formore than 60% of the root causes ofsentinel events reported to the JointCommission (JC). In a 2001 case, apatient died after labetalol, hydrala-zine, and extended-release nifedipinewere crushed and given by NG tube.(Crushing extended-release medica-tions allows immediate absorption ofthe entire dosage.) As a result, thepatient experienced profound brady-cardia and hypotension leading tocardiac arrest. Although she was suc-cessfully resuscitated, she receivedthe drugs the same way the nextday. Clinicians had failed to commu-

nicate to other team members thather initial cardiac arrest had occurredshortly after shed received the med-ications improperly.

Drug packaging, labeling, andnomenclatureHealthcare organizations should en-sure that all medications are provid-ed in clearly labeled unit-dose pack-ages for institutional use. Packagingfor many drugs looks similar. Atragic case stemming from such sim-ilarity occurred with heparin (one ofthe drugs on the JCs high-alertlist, meaning it has a high potentialfor causing patient harm). A fewyears ago, several pediatric patientsreceived massive heparin overdosesdue to misleading packaging and la-beling; three infants died. As a re-sult, the Food and Drug Administra-tion and Baxter Healthcare (theheparin manufacturer) issued a let-ter via the MedWatch program alert-ing clinicians to the danger posedby similarly packaged drugs. Baxterhas since enhanced the labels onheparin and some other high-alertdrugs; it now uses a 20% larger fontsize, tear-off cautionary labels, anddifferent colors to distinguish differ-ing drug dosages.

Look-alike or sound-alike medica-tionsproducts that can be confusedbecause their names look alike orsound alikealso are a source of er-rors. From 2003 to 2006, 25,530 sucherrors were reported to the Medica-tion Errors Reporting Program (oper-ated jointly by the U.S. Pharma-copeia and ISMP) and MEDMARX

(an adverse drug event database).The JC requires healthcare institu-tions to identify look-alike andsound-alike drugs each year andhave a process in place to help en-sure related errors dont occur.

Medication storage, stock,standardization, and distributionMany experienced nurses remem-ber when critical care units kept amedication stash, which frequent-ly caused duplication errors. Poten-tially, many errors could be pre-vented by decreasing availability offloor-stock medications, restrictingaccess to high-alert drugs, and dis-tributing new medications from thepharmacy in a timely manner.

Also, hospitals can use commer-cially available products to decreasethe need for I.V. compounding med-ications and I.V. admixing. Use ofpreprinted order sets and standard-ized formularies can reduce errors,too. The Institute for Healthcare Im-provement recommends standardizedorder sets and preprinted protocolsfor 75% of the drugs healthcare facili-ties use. These orders and protocolshelp clinicians promptly select correctdosing regimens, routes, and parame-ters while eliminating ambiguous ab-breviations and the risk of misreadinga prescribers handwriting.

However, errors can occur evenwhen automated dispensing cabi-nets are stocked by technicians. Ina recent error reported to the ISMP,a technician filled an automateddispensing cabinet with the wrongconcentration of a premixed potas-sium chloride I.V. solution.

Drug device acquisition, use,and monitoringImproper acquisition, use, andmonitoring of drug delivery devicesmay lead to medication errors.Some delivery systems have inher-ent flaws that increase the errorrisk. For example, at one time, I.V.medication tubing continued toflow or infuse when removed fromthe pump. Thus, patients could re-

Sobering statisticsIn 2008, researchers estimated that potentially preventable adverse drug events kill7,000 Americans annually and that medication errors that result in harm are the num-ber-one cause of inpatient fatalities.While error rates vary widely among facilities, ex-perts believe at least one medication error occurs per hospital patient every day.

Medication errors pose the greatest risks and consequences in critical care set-tings, where patients are sicker and lack the resilience to respond adequately to anadverse event. Whats more, critical care patients typically receive twice as manymedications as patients on general floors. Approximately 20% of critical care med-ication errors are potentially life-threatening, and 42% of these errors necessitateadditional life-sustaining treatments.


ceive boluses of medications or I.V.solutions, which sometimes haddeleterious outcomes. During theadmission process, for instance, apatient receiving nitroprussidecould receive a large infusion ofthis drug when the I.V. tubing wasremoved from the pump and thepatient was transferred from onebed to another. This design flawhas since been resolved. In addi-tion, syringes for administering oralmedications should not be compati-ble with I.V. tubing.

Environmental factorsEnvironmental factors that can pro-mote medication errors include inad-equate lighting, cluttered work envi-ronments, increased patient acuity,distractions during drug preparationor administration, and caregiver fa-tigue. (See The fatigue factor.)

Distractions and interruptions candisrupt the clinicians focus, leadingto serious mistakes. To reduce inter-ruptions, Sentara Leigh Hospital inNorfolk, Virginia has instituted a nointerruption zone around the auto-

mated medication dispensing ma-chines; coworkers know not to in-terrupt a nurse whos obtainingmedication from the machine.

Heavier workloads also are associ-ated with medication errors. Thenursing shortage has increased work-loads by increasing the number of pa-tients for which a nurse is responsi-ble. Also, nurses perform many tasksthat take them away from the pa-tients bedside, such as answering thetelephone, cleaning patients rooms,and delivering meal trays. Absence of

The fatigue factorRecent research highlights the role of caregiver fatigue in medicationerrors. Nurses who responded to a 2008 medication safety survey re-ported that fatigue, stress, and understaffing increased the risk ofmaking a medication error.

Over the last few decades, workplace fatigue has been exploredfrom various perspectives. In a study comparing performance during12-hour shift rotations by different age-groups, researchers foundthat compared to their 20-somethingcounterparts, older workers experiencedmore sleep disruptions, were less able toadjust their circadian rhythms, andwerent as adept at maintaining theirperformance over the shift. (The averageage of U.S. registered nurses is 46.8.)

Fatigue and sleep deprivation arelinked to decreases in vigilance, mem-ory, information processing, reactiontime, and decision making. A personwho works a 12-hour shift and has along commute may need to stay awakefor up to 18 consecutive hours. Accord-ing to U.S. Army studies, staying awakefor 17 hours is equivalent to a blood alcohol level of 0.05%; stayingawake for 24 hours equates to a blood alcohol level of 0.10%. Nurseswho work a 16-hour shift may be awake for up to 19 or 20 hours, es-pecially if they have a long commute. Loss of even one nights sleepcan lead to short-termmemory deficitsand omission errors and giv-ing the wrong drug are commonmedication errors.

Fatigue and sleep loss also may diminish a nurses ability to rec-ognize subtle patient changes. As a result, the nurse may not noticean adverse reaction to a drug quickly enough to avoid a devastatingoutcome.

Near-missesSuppose a physician writes an order on the wrong chart, but youcatch the error before the patient is harmed. A 2006 study found 350such near-misses were reported, with drug administration implicatedin 28.2%. Due to decreased vigilance and reduced information-pro-cessing ability, a severely fatigued nurse may not notice a potentialproblem that could make the difference between a near-miss and amedication error.

Near-miss medication error reporting can be used to reduce med-ication errors. Near-miss data are reviewed and analyzed to identify

the circumstances that led to the problem, and appropriate error re-duction strategies can be implemented. Failure to recognize and re-port near-misses impedes efforts to improve medication safety.

TragicWisconsin caseFatigue contributed to a serious medication error inWisconsin. Afterworking a 16-hour shift, a labor/delivery nurse came in the next morn-

ing to work another shift. Because shedhad only a few hours off between shifts,shed arranged to sleep at the hospital.Late in the morning of the second day,she admitted a young patient. Thephysician had ordered an antibiotic tobe given right away. The nurse pickedup what she thought was the antibioticand hung it without scanning the pa-tient or the medication. Tragically, thedrug she actually gave wasnt the antibi-otic but bupivacaine-fentanyl, anepidural anesthetic. The patient diedwithin an hour. Initially, the nurse wascharged with felony neglect of a patient

causing great bodily harm, but pled guilty to the misdemeanor of dis-pensing and illegally obtaining a prescription. Her nursing license wassuspended for 9 months and she was barred fromworking in an ob-stetric or critical care area or working any shift longer than 12 hours.

InattentionalblindnessAnother case of a fatigue-related error involved misreading of druglabels. A nurse nearing the end of a 16-hour shift reached into themedication supply cabinet to obtain furosemide I.V. She thought shewas grabbing a furosemide vial, but picked up a vial of potassiumchloride instead.

The vial was correctly labeled, and the nurse even read the label be-fore administering the drug (which caused a fatal arrhythmia). Thefurosemide and potassium chloride labels had similar colors and printing.The nursewas expecting to seefurosemideon the label, so her brainprocessedwhat she expected to see. Such inattentionalblindnessoc-curs when the brain fails to distinguish something that should be easy todiscern. To prevent information overload, the brainsearches and sweepsuntil something grabs its attention. Its adept at filling in gapswhen infor-mation ismissing, compiling a comprehensive picture based on incom-plete information. Thus, the nurse sawwhat she expected to see.


nurses from the bedside is directlylinked to compromised patient care.

Staff education and competencyContinuing education of the nursingstaff can help reduce medication er-rors. Medications that are new tothe facility should receive highteaching priority. Staff should re-ceive updates on both internal andexternal medication errors, as an er-ror that has occurred at one facilityis likely to occur at another. (Theheparin overdoses described earlierhappened at multiple institutions.)

As medication-related policies,procedures, and protocols are updat-ed, this information should be madereadily available to staff members.Also, nurses can attend pharmacygrand rounds. Some facilities nowuse nursing grand rounds as a wayto keep staff members competent.

Patient educationCaregivers should teach patients thename of each medication theyretaking, how to take it, the dosage,potential adverse effects and inter-actions, what it looks like, andwhat its being used to treat.

Quality processes and riskmanagementA final strategy for reducing med-ication errors is to establish ade-quate quality processes and risk-management strategies. Everyfacility should have a culture ofsafety that encourages discussion ofmedication errors and near-misses(errors that dont reach a patient) ina nonpunitive fashion. Only thencan effective systems-based solu-tions be identified and used.

Simple redundancies, such as us-ing an independent double-checksystem when giving high-alertdrugs, can catch and correct errorsbefore they reach patients. Accord-ing to the Institute of Medicine, or-ganizations with a strong culture ofsafety are those that encourage allemployees to stay vigilant for un-usual events or processes.

Consequences for the nurseFor a nurse who makes a medica-tion error, consequences may in-clude disciplinary action by thestate board of nursing, job dis-missal, mental anguish, and possi-ble civil or criminal charges. In onestudy of fatal medication errorsmade by healthcare providers, theproviders reported they felt immo-bilized, nervous, fearful, guilty, andanxious. Many experienced insom-nia and loss of self-confidence.

Avoiding medication errorsHow can you safeguard your prac-tice from medication errors? Forstarters, be conscientious about per-forming the five rights of medica-tion administration every timeright patient (using two identifiers),right drug, right dosage, right time,and right route. Some experts haveexpanded this list to include: right reason for the drug right documentation right to refuse medication right evaluation and monitoring.

Be sure to use the safety re-sources available at your facility.Dont use workarounds to bypasssafety systems. In a 2008 study,one-third of nurses reported theysometimes bypass safety systems.Nurses working in critical care andpediatrics were more likely to dothis; yet medication errors in thesesettings can be particularly devastat-ing. Where nurses routinely bypasssafety systems and create work-arounds, the employer must con-duct a root-cause analysis to identi-

fy the reason for the workaround,and take action to correct the situa-tion and prevent recurrences.

Additional steps you can take topromote safe medication use include: reading back and verifying med-

ication orders given verbally orover the phone. (See Readingback medication orders.)

asking a colleague to double-check your medications whengiving high-alert drugs

using an oral syringe to adminis-ter oral or NG medications

assessing patients for drug allergiesbefore giving new medications

becoming familiar with your facili-tys do not use list of abbrevia-tions. In 2004, the JC published alist of abbreviations that shouldntbe used because they can con-tribute to medication errors. Forinstance, in one documented case,a naked decimal point (onewithout a leading zero) led to afatal tenfold overdose of mor-phine in a 9-month-old infant.The dosage was written as .5mg and interpreted as 5 mg.

Eliminating medication errorsAvoiding medication errors requiresvigilance and the use of appropriatetechnology to help ensure properprocedures are followed. Computer-ized physician order entry reduceserrors by identifying and alertingphysicians to patient allergies ordrug interactions, eliminating poorlyhandwritten prescriptions, and giv-ing decision support regarding stan-dardized dosing regimens.

Reading back medication ordersThe Joint Commission recommends caregivers read back and verifyall medication orders given verbally or over the telephone. Keepthese tips in mind: Have the patients chart available when calling the prescriber, and

write down the order while youre still on the phone. Verify the patients name. Read back and confirm the medication. If youre unfamiliar with

the drug, ask the prescriber to spell the drug name. Confirm themedication dosage by stating each number individually. To help prevent sound-alike errors, verify with the prescriber the

condition that the medication is being used to treat. For example,Actos is used for diabetes mellitus, whereas the similar-soundingActonel is used to treat osteoporosis.


The Leapfrog Group (whose mis-sion is to trigger giant leaps for-ward in healthcare safety, quality,and affordability) supports comput-erized physician order entry as away to reduce medication errors.Use of computerized physician or-der entry and barcodes may reduceerrors by up to 50%.

Yet computerization cant pre-vent or catch all errors. In onenear-miss incident, an I.V. bag of astandardized diltiazem (Cardizem)solution (125 mg in 125 mL normalsaline solution) was inadvertentlylabeled as an insulin drip, eventhough it had scanned correctly(the barcode had been applied bythe pharmacy). Fortunately, an alertICU nurse realized the bag she hadin her hand was a premixed solu-tion and not a pharmacy admixture.When she turned it over, she couldsee the manufacturers label.

Be sure to use the safety prac-tices already in place in your facili-ty. Eliminate distractions whilepreparing and administering med-ications. Learn as much as you canabout the medications you adminis-ter and ways to avoid mistakes.(See Websites that can help youavoid medication errors.) Finally,be aware of the role fatigue canplay in medication errors.

Selected referencesConsumers Union. To Err is HumanTo De-lay is Deadly. May 2009. www.safepatientproject.org/safepatientproject.org/pdf/safe

patientproject.org-ToDelayIsDeadly.pdf. Ac-cessed February 1, 2010.

Institute for Safe Medication Practices. ISMPMedication Safety Alert! Nurse Advise-ERR[Newsletter]. http://www.ismp.org/Newsletters/nursing/default.asp. Accessed February 1, 2010.

Hicks RW, Becker SC, Cousins DD. MED-MARX data report. A report on the relation-ship of drug names and medication errors inresponse to the Institute of Medicines callfor action. Rockville, MD: Center for the Ad-vancement of Patient Safety, U.S. Pharma-copeia; 2008.

Kohn LT, Corrigan JM, Donaldson MS, eds.To Err is Human: Building a Safer HealthSystem. Washington, DC: National AcademyPress; 2000.

Koppel R, Wetterneck T, Telles J, Karsh B.Workarounds to barcode medication admin-istration systems: their occurrences, causes,and threats to patient safety. J Am Med In-form Assoc. 2008;15(4):408-423.

Rogers A, Hwang W, Scott L, Aiken L,Dinges D. The working hours of hospitalstaff nurses and patient safety. Health Aff(Millwood). 2004;23(4):202-212.

Sakowski J, Newman J, Dozier K. Severity ofmedication administration errors detected by abar-code medication administration system. AmJ Health Syst Pharm. 2008;65(17):1661-1666.

Visit www.AmericanNurseToday.com/archives.aspx for a complete list of selected references.

Pamela Anderson is an adult nurse practitioner nurseat Clarian Health in Indianapolis, Indiana; a resourcepool float nurse at Ball Memorial Hospital in Muncie,Indiana; and a p.r.n. ICU nurse at Tipton Hospital inTipton, Indiana. Terri Townsend works in the cardio-vascular ICU and the cardiac telemetry unit at Ball Me-morial Hospital and holds an adjunct clinical facultyposition at Ball State University School of Nursing inMuncie. The planners and authors of this CNE activityhave disclosed no relevant financial relationships withany commercial companies pertaining to this activity.

Websites to help you avoid medication errorsThe websites below provide accurate information about the consequences of med-ication errors and ways to avoid such errors.

Drugs and lactation database (National Library of Medicine)http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

Epocrates electronic drug resourcewww.epocrates.com

FDA MedWatchwww.fda.gov/Safety/MedWatch/default.htm

Institute for Safe Medication Practiceswww.ismp.org

MedlinePlus: Drugs, Supplements, and Herbal Informationwww.nlm.nih.gov/medlineplus/druginformation.html

National Coordinating Council for Medication Error Reporting and Preventionwww.nccmerp.org

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Please circle the correct answer.1. According to 2006 statistics from the Institute ofMedicine, how many Americans are injured by medica-tion errors each year?

a. 2 millionb. 1.5 millionc. 1.25 milliond. 1 million

2. Administration errors account for what percentageof medication errors?

a. 5% to 12%b. 15% to 24%c. 26% to 32%d. 50% to 75%

3. Critical care patients receive how many medicationscompared to patients on a general unit?

a. Twiceb. Halfc. One-fourthd. One-eighth

4. Which statement about barcode scanning iscorrect?

a. Barcode scanning initially reduces medicationadministration time.

b. Barcode scanning initially increases medicationadministration time.

c. Barcode scanning has been found to be fail safe.d. Barcode scanning has been found to be too

expensive for practical use.

5. A communication method that can help reducemedication errors is:

a. RABT.b. SBAR.c. SABT.d. ABRS.

6. Poor communication accounts for what percentageof the root causes of sentinel events?

a. 30%b. 40%c. 50%d. 60%

7. Which statement about standardized order sets andpreprinted protocols is accurate?

a. They should be used for 50% of the drugs health-care facilities use.

b. They do not help reduce medication errors in thehospital.

c. They help reduce errors by prompting clinicians toselect correct dosing.

d. They are appropriate only for use in hospital inten-sive care units.

8. Which of the following is a strategy for preventingmedication errors by limiting drug availability?

a. Increasing the availability of floor-stock medicationsb. Decreasing the availability of floor-stock medicationsc. Allowing easier access to high-alert drugsd. Delaying the distribution of new medications from

the pharmacy

9. Which of the following is an environmental strategyto reduce medication errors?

a. Store multiple resource papers in the medicationarea.

b. Have two nurses prepare each medication.c. Establish a no interruption zone around dispensing

machines.d. Keep room lights dim to avoid distractions.

10. What is the blood-alcohol equivalent of stayingawake for 17 hours?

a. 0.05%b. 0.04%c. 0.3%d. 0.02%

11. Some experts suggest expanding the five rightsof drug administration to include which other right?

a. Right dosageb. Right reasonc. Right timed. Right route

12. In a 2008 survey, how many nurses reported thatthey sometimes bypass safety systems?

a. One-eighthb. One-fourthc. One-thirdd. One-half

13. Which of the following does the Joint Commissionrecommend caregivers do when taking verbal ordersfrom prescribers?

a. Verify the condition that the medication is beingused to treat.

b. Explain that youre not allowed to take verbal orders.c. Have a third person listen in on the conversation.d. Call the prescriber from the patients room.

14. Which of the following strategies does not promotesafe medication use?

a. Repeating back a verbal or telephone order from aprescriber

b. Using an I.V. syringe when giving nasogastric med-ications

c. Using a zero before the decimal point in a dosageless than 1

d. Having a colleague double-check when you admin-ister high-alert drugs

15. Use of computerized physician order entry andbarcodes may reduce medication errors by up to:

a. 15%.b. 25%.c. 50%.d. 75%.

Evaluation form (required)

1. In each blank, rate your achievement of each objective from 1 (low/poor) to 5(high/excellent).(1.) Identify the 10 key elements of medication use. ____(2.) Describe the role of clinician fatigue in medication errors. ____(3.) Discuss strategies to prevent medication errors. ____

Purpose/goal: To provide nurses with information to help themprevent medication errors

Also rate the following from 1 to 5.2. The relatedness and effectiveness of the purpose, objectives, content, andteaching strategies. ____3. The author(s)competence and effectiveness. ____4. The activity met your personal expectations. ____5. The application to and usefulness of the content in your nursing practice. ____6. Freedom from bias due to conflict of interest, commercial support, productendorsement or unannounced off-label use. ____7. State the number of minutes it took you to read the article and complete thepost-test and evaluation. ____

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POST-TEST Medication errors: Dont let them happen to youEarn contact hour credit online at www.americannursetoday.com/ContinuingEducation.aspx (ANT100301)

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