Running head: MEDICATION ERRORS

Medication Errors
Jennifer Shippert
University of South Florida

MEDICATION ERRORS

Medicationerrorsareamongthemostcommonandpreventableadverseeventsthatoccur
onadailybasisintheUnitedStates.Errorsarepartofhumanlife,infact64.5%ofnursesreport
makingsomesortofmedicationerror.Althoughmosterrorscanbeminiscule,otherscanbe
catastrophictoapatientshealth.Medicationadministrationisoneofthemostimportant
responsibilitiesofanursesjob.Onemistakecancauseincreasedmedicalexpenses,increased
hospitalstay,andincreasedmortality.
Withthousandsofdrugsonthemarket,itwouldbenearlyimpossibleforanyonetoknow
alltheadverseeffects,labvalues,andsideeffectsofeverymedication.Withthedemandfor
nursesontherisethereisalargerpatienttonurseratio.Youcanseethecombinationoftheseto
factorswouldchaosinanytypeofhealthcaresetting.Thereisalsoacorrelationbetweenerrors
andfatigue,andmanysourcescitethenursingshortageofhealthcareproviders(especiallyin
nursing),presentinnumerouscountriesaroundtheworld,asamajorfactorintheincreasein
medicationerrors(Young,Koopsen,Farb,2005).
Asanurse,theadministrationofmedicineisintendedtobeacompletelybeneficial
action,whichhopefullyassistsintheprogressionofthepatientsrecoveryand/orcomfort.With
themanyresponsibilitiesandstressesthatanurseencountersonadailybasis,itisnothardtosee
howoverlookingaseeminglysmalldetailisnotoutoftherealmofpossibility(e.g.alabvalue).
Labvaluesareusedasapatientsuniquebaselinetocomparetheirvaluetothenormalexpected
values.Ittestsbodilyfluidssuchasblood,gastricacid,cerebralspinalfluid,urineandstool.
Thesevaluesareabletohelphealthcareworkersdiagnoseandunderstandwhatisgoingonwith
apatientsbodyinordertodetermineaneffectivemethodoftreatment.Medication,age,and
ethnicityareallfactorsthatcanaffectyourbloodchemistry.

MEDICATION ERRORS

Unfortunately,somenursesmaynotunderstandhowcrucialcheckinglabsbeforegiving
medicationis.Manydrugsavailableontodayspharmaceuticalmarketcanhavedirectseffects
onvariouscomponentssuchasmolecules/ionswithinthebloodstream.Forexample,thedrug
Lasixcancauseaseveredepletion,andthereforeimbalance,oftheelectrolytepotassium.Before
givingthisdrug,thenursewouldwanttocheckthisvaluetodetermineifthedoseneedstobe
heldorifitissafetoadminister.Inthiscase,overlookingthislabvaluecouldcauseafatalheart
dysrhythmia.
Sincelabvaluesarenotpartofthesixrightsofmedicationadministration,nursesmust
remembertoimplementthiscrucialstepintotheirmedicationroutines.Asstatedpreviously,itis
nearlyimpossibletoknoweverysingledrugonthemarket.Beforeadministeringanunfamiliar
medicationthenurseshouldresearchthemedication.Thisextra,yetsimplestepwillgivethe
nurseaninsidelookoncriticallabvaluesthatneedtobeevaluated,sideeffects,mechanismof
action,implementations,andotherpertinentinformation(Cloete,2015).
Trainingcoursesonmedicationadministrationcouldalsopotentiallyreducethenumber
ofincidencesencounteredwithrespecttomedicationerrors.TheContinuousQuality
ImprovementModel(CQIM)isanevidencedbasededucationprogramthatfocusesonthe
scopeofmedicationerrors.Thisthreepartonlineprogramisfocusedonstrategiesthatimprove
medicationerrors.Pretestsareusedasaaninitialbaselineofknowledgeandposttestsaregiven
totheparticipantuponcompletionofthecourse.Astoundingly,thereisa95%satisfactionrate
withtheaforementionedCQIMandthesenursesalsoadmittoapplyingatleastoneofthesafety
strategiesfromlearnedfromtheprogrammodules(Harris,2014).

MEDICATION ERRORS

InonlyafewshortmonthsIwillbearegisterednursewiththeresponsibilityofbeing
abletopassmedicationwithoutthesupervisionofaclinicalinstructororanothernurseisan
intimidatingone.MyunfortunateunwillingnesstospeakupformyselfisaflawIpossessthat
couldpotentiallyleadtoamedicationerror.Ifaphysicianoranursesupervisoraskedmetopass
amedicationthatwascontraindicated,IfeelasthoughImaynothavethewillpoweror
confidencetoadvocateformypatient.AsanurseIknowthiswillbeahugepartofmycareer
andisaqualitythatIamworkingonnotonlyintheworkplace,butineverydaylife.Ihavebeen
workingonthislackofconfidencebyfamiliarizingmyselfwithmedicationsandworkingonmy
assertiveness.
Thoughliteratureindicatesthatmedicationerrorsamonghealthcareprofessionalsand
alliedhealthprofessionals,alike,arebynomeansrareoccurrences,theyareextremely
dangerousonesthatcanenduphavingdisastrousconsequences.Itisimportantthatwe,as
nurses,paycloseattentiontodetailandgotheextramiletoensurethatwearealwaysproviding
thehighestlevelofqualitycaretoourpatients.Thoughweareexpectedtojuggleawidevariety
ofservicesforalargenumberofpatientssimultaneously,itisourdutytodosoeffectivelyand
withasfewmistakesashumanlypossible;whilemakingsurenottoletthepressuresofsuch
responsibilityaffectourperformanceonthejob.Aspreviouslymentioned,althoughmedication
errorsareamongthemostcommonmistakesmade,theyarealsoamongthemostpreventable;a
silverliningourhealthcaresystemanditsworkersshouldquicklytakenoticetoandaddress.

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References
Cloete,L.(2015).ReducingMedicationErrorsinNursingPractice.NursingStandard,
29(20),5059.
Harris,R.(2014).ImprovingPreceptorsKnowledgeonMedicationErrorStrategies.
MedSurgNursing,23(6),402407
Young,C.,Koopsen,C.,&Farb,D.(2005).MedicationErrorsGuideBook.Los
Angeles:UniversityofHealthcare.

MEDICATION ERRORS