Running head: MEDICATION ERRORS 1

Medication Errors

Olivia Meitzner

University of South Florida

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Medication Errors

Errors are commonplace in everyday life yet can be disastrous in the healthcare field. It is

astonishing that thousands of people are affected negatively each year as the result of medication

errors. What is even more shocking is that these preventable errors are carried out by the very

people whose profession is defined as providing care to the sick and whose main goal is patient

safety. It is vital that healthcare professionals have knowledge of the most common medication

errors reported and the top reasons why they occur so they can break the chain of careless

medical errors. Healthcare professionals should also have interventions in place to reduce the

frequency of medication errors to improve patient safety. Nurses should be cognizant of how

their actions affect not only their patients, but also the patient’s families, their co-workers and the

community at large. Nursing students must take careful notice of the common and preventable

mistakes made in practice, so they can make a conscious effort to eliminate any medication

errors they may make in the future.

Common Medication Errors

There is a plethora of medication errors that can occur and countless factors contributing

to the cause. One of the most common mistakes seen in practice is giving the wrong dose of a

drug. This mistake can occur for numerous reasons, a good example being distraction in the

workplace. It is not a secret that hospitals are noisy environments. From various beeping

machinery to what seems like continuous patient and staff requests, the environment of a hospital

can seem almost chaotic. Unfortunately, many nurses become sidetracked and distracted in this

environment which leads to errors in any part of the six rights of medication administration.

These distractions and interruptions can lead a nurse to overlook or rush the process of checking

dosages. Distractions and interruptions can also account for another common medication error,
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being inaccurate frequency of the medication. Mistakes can also be made in the medication

dosage and frequency by lack of pharmacological knowledge of certain medicine. For example,

if you don’t know that digoxin has a narrow therapeutic index and is usually given in really small

doses, you wouldn’t question an order for 2 mg PO daily. This seemingly small number would

result in digoxin toxicity which can also go undiscovered because toxicity includes common side

effects like diarrhea and vomiting (MacLeod-Glover, Mink, Yarema & Chuang, 2016). Another

common medication error is giving the wrong drug. This can occur simply if people abbreviate

and use acronyms that are inaccurate and/or look similar to other drug names. (Tariq & Scherbak,

2019). This mistake can have the most serious outcome, as the medication was not intended to

be given to the patient or might be contraindicated for the patient and produce unexpected

adverse effects. Occasionally medication errors can occur by the patient’s hand, but only because

they don’t know any better and their nurse failed to communicate and educate them. Patients

may fail to take the drug as prescribed or take too much or too little of a drug. To give an

example, a patient could crush a pill that is enteric coated or stop taking a hypertension drug

every day when their blood pressure returns to normal. While some of this can happen by no

fault of the nurse, many times it is the lack of clear communication and education to patients at

discharge that leads to medication errors by patients.

Impact on Patients and Families

It is believed that preventable medication errors impact more than 7 million patients and cost

almost $21 billion annually across all care settings (Da Silva, & Krishnamurthy, 2016). There

are serious effects and consequences to making medication errors in the healthcare field. For

example, giving the wrong dose of digoxin can cause serious heart dysrhythmias that can

become physically disabling for a patient resulting in the prolonged and expensive hospital stays
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(MacLeod-Glover, Mink, Yarema & Chuang, 2016). While the obvious effect of medication

errors is potential harm to the patient, there is also the aspect of damaging the rapport you have

built with your patient and your patients’ family. From the time of admission nurses are working

towards building a trusting relationship with their patients. Building this trust will put the

patients mind at ease and help them focus on getting better rather than worrying about whether or

not they are receiving the care they deserve. When medication errors occur, patients lose faith in

their nurses which can ultimately lead to loss of faith in the healthcare system. When errors

significantly affect a patient, family members are also significantly affected as well. Family

members may become extremely angry and frustrated with the hospital staff and these feelings

can and will impact their future interactions and experiences with the healthcare system. It is

vital that nurses remember that medication errors can result in psychological, physical pain and

unnecessary suffering.

Avoiding Medication Errors

There is no simple fix to avoiding medication errors. In fact, the ‘solution’ to reducing

medication errors is quite complex and multi-faceted. It involves every healthcare team member

and requires a considerable amount of time and effort. There are several nursing interventions

that can be implemented to reduce the number of mistakes made. For instance, making sure

everyone is aware of and follows the “quiet” area rule when retrieving medication will help with

the distraction and interruption issue. As for the lack of pharmacological understanding of certain

drugs, nurses have numerous resources to get the information they need. There are usually

pharmacists on each floor that can assist with any questions as well as online reference manuals

that can give detailed summaries of vital information such as: why it’s given, how it’s given,

usual doses, side effects, contraindications, and much more. Nurses should always be
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knowledgeable of the drugs they are administering so they can accurately educate their patients

and help prevent medication errors when the patient is discharged. Another general but extremely

effective way to avoid medication errors is to provide clear and accurate communication between

all healthcare team members as well as patients and their families. Nurses must also take the time

to listen to family members of the patient as they are usually the best advocates and know their

normal and abnormal behaviors better than anyone. If a family member is questioning a drug you

are giving, take a step back and reflect, even investigate why they may be troubled. While there

are countless ways to try and reduce the amount of medication errors, nothing will stop them

from occurring completely. When mistakes do happen, it is a nurse’s responsibility to report the

error and learn from the mistake.

Impact on students

Starting clinical was the most exciting yet terrifying experience of nursing school thus

far. I was eager to put my skills to practice, one being medication administration, but I knew that

making a mistake could have serious consequences and potentially harm my patient. During

clinical I have begun to contemplate what mistakes I could potentially make in the future. One

error that I am concerned of making is giving the medication at the wrong time. We are allotted

an hour before and an hour after to administer medications to each of our patients, yet we can

potentially have five patients who may all need medication around the same time. Congruently,

we also have to make sure we are knowledgeable on the medications we are giving, which takes

time to research to ensure patient safety. While I am a little concerned about how I will manage

punctual medication administration, I have a few ideas that may help me in the future. First and

foremost, at the beginning of each shift I will create an organized schedule that will include each

medication needed for my patients as well as the time frame I have to give them, making sure to
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prioritize the medications that are time sensitive. Then I will make sure that I research the

medications I am not familiar with so I can properly educate my patients. I will also make sure

when I am retrieving medication, I am not interrupted during the process which will help reduce

the possibility of error and help with time management. One other medication error I am worried

I might make is giving the wrong dosage. This is a two-fold issue as I might give the wrong

dosage because I make a mistake with my calculations, or I might not know the normal dosage

range for a medication, so I don’t report that to the pharmacist or physician. I plan on preventing

this error by making sure I always triple check my math and if I’m still unsure I will have

another nurse check my work. I will also make sure I do the appropriate research on any

medications I am unsure about to confirm that the dosage is within the normal limits for my

patient.

Conclusion

During my research, my eyes were opened to how common medication errors are. As

nurses are the last person to potentially catch a medication error, it is tremendously important

that they take the time necessary to check the six rights of medication administration, be

knowledgeable of the medications they are administering, and work with colleagues to maintain

a safe work environment. I now have the resources and the knowledge to make ethical and safe

work decisions regarding medication administration and will apply this knowledge as I continue

my clinical practice.
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References

Da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: A

patient case and review of Pennsylvania and National data. Journal of Community

Hospital Internal Medicine Perspectives, 6(4), p. 31758. doi:10.3402/jchimp.v6.31758

MacLeod-Glover, N., Mink M., Yarema M. and Chuang R. (2016). Digoxin toxicity: Case for

retiring its use in elderly patients? Canadian Family Physician, 62(3), p. 223-228.

Retrieved from http://www.cfp.ca/content/cfp/62/3/223.full.pdf

Tariq R.A., Scherbak, Y., (2019). Medication Errors. StatPearls Publishing. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK519065/