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DiversityNursing Blog

What You Need to Know About Medication Errors

Posted by Sarah West APRN, FNP-BC

Mon, Dec 19, 2022 @ 02:19 PM

GettyImages-1344059941-2Healthcare workers, especially Nurses, face more challenges today than ever. Nurses must quickly adapt to fluctuating Nurse-Patient ratios, evolving technology, and the evolutions of healthcare and how it affects the way we provide care to our patients. Medication errors are an unfortunate consequence of overwork, distraction, and system errors. The consequences of medication errors can range from minor to serious. Serious medication errors can even result in death.

Causes of Medication Errors

Medication errors can be the result of any failure to ensure that the correct medication is being administered. Clinicians, pharmacy staff, and Nurses all play a critical role in ensuring patients receive the proper medications. Clinicians must ensure that the correct medications, dosages, and routes are being ordered. Pharmacy staff must double-check the ordering clinician and then input the correct medication, dosage, and route are being entered into the electronic system. Then Nurses must check the information again before administering the medication. Even though errors can occur anywhere along this chain, Nurses carry the ultimate responsibility to check and double-check every medication they administer.

How You Can Prevent Medication Errors

No well-intentioned Nurse wants to make a medication error. Nurses are the front line of healthcare, and it is up to us to prevent errors from occurring whenever possible. Here are some things you can do to keep your patients safe and avoid medication errors.

Avoid Distractions: Avoiding distractions can sometimes be easier said than done. Nurses are constantly juggling the tasks and needs of several different patients at the same time. Distractions that can lead to medication errors can be caused by ringing phones, call lights, IV pump alarms, and interruptions by family members or coworkers.

Nurses tend to work in high-stress situations, which can lead to distraction. Whenever possible, you should avoid distractions while preparing or administering medications. Medications should be prepared in the patient’s room and double-checked to the electronic record to prevent errors from occurring.

Check the Five ‘Rights: The five rights to correct medication administration is a simple, but effective method to ensure that medications are being administered safely and correctly. Before administering any medication, make sure that you verify all five rights.

1. Right Patient
  • Check the name on the order and verify the correct patient using 2 identifiers. Ask the patient their name and date of birth and check that their wrist band displays the same information.
2. Right Medication
  • Check all medication labels and compare them to the original order to ensure they are the same medication. At this time, you could also check the medication’s expiration date and ask the patient if they have any medication allergies.
3. Right Dose
  • Check the ordered dose and compare it to the medication on hand. Confirm that the dose is appropriate for your patient.
4. Right Route
  • Medications can be administered in many different ways, including but not limited to orally, intravenously, topically, and intramuscularly. Nurses must always ensure that medications are being given via the correct route.
5. Right Time
  • Check the order and ensure the correct time for the medication. Check the frequency of the medication and the last dose the medication was given.

Double Check Medications with a Coworker: High-alert medications can have serious consequences if not administered correctly. High-alert medications are any medications with a heightened risk of causing significant harm if administered incorrectly. Medications like heparin are considered high-alert medications due to the increased risk of bleeding to patients who receive it. Nurses should double-check all high-alert medications and any medication that can look or sound like other medications with another Nurse to help reduce the risk of medication errors.

Document: Medication administration should always be documented. Bar code scanners on electronic medical records should always be used to ensure medications are not only documented, but have been given correctly.

Speak Out: As Nurses, our priority should always be patient safety. If you identify a potential for medication errors to occur, speak to your supervisor to make a change.

Patient safety should be the number one concern for all healthcare professionals. As Nurses, we play a vital role in preventing medication errors. It may not be possible to avoid every medication error, but as Nurses, we must prioritize safe medication administration to ensure our patients receive safe and effective patient care.

Topics: medication errors, medical errors

IdentRx Promises to Prevent Nearly All Medication Errors

Posted by Erica Bettencourt

Wed, Apr 29, 2015 @ 11:08 AM 

describe the imageMedication errors continue to plague the clinical community and even rare cases of mistakes can make a big splash in the news. And for a good reason: we all expect to be treated than harmed when receiving medical care. A new device is currently in the third round of pilot testing, including at major retail pharmacies and Purdue University, that may help avoid prescription errors altogether. The IdentRx system from PerceptiMed, a Mountain View, California firm, optically analyzes every single pill that will be given to a patient to make sure it precisely matches each prescription.

It is the only device that visually inspects each pill, recognizing the manufacturer imprints on them all. The system confirms that the pills themselves, and not only the container bottles, match the issued prescriptions, hopefully preventing errors just before the pills are handed to the patients.

Topics: medical technology, prescription, medication errors, technology, health, healthcare, medication, medical, patients, medicine, patient

Helping patients to reduce medication errors

Posted by Pat Magrath

Fri, Sep 09, 2011 @ 11:40 AM

Mr. W had a heart attack and was in the ICU last week.  While reviewing his discharge medication list, you realize Mr. W unintentionally discontinued his medication for hypertension and dyslipidemia.  Unfortunately, these medications were not on the discharge medication list.  

Jay has been a well controlled diabetic for many years.  Today his A1C is 10.5.  He insists he is taking his medication regularly.  

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 health care professional, patient, or consumer. 1   Efforts to decrease or prevent medication errors often focus on improving systems and procedures utilized by nurses, physicians and pharmacists during the multistep process of medication administration.  Decreasing medication errors by patients must also be addressed.  

According to the landmark 2006 report "Preventing Medication Errors" from the Institute of Medicine, medication errors injure 1.5 million Americans each year and cost 3.5 billion in lost productivity, wages and additional medical expenses.​2 1/3 of medication errors occur in outpatient settings.  Patients often unintentionally discontinue medications after a hospitalization or transfer of care.  Numerous studies have shown that patients with chronic conditions adhere only to 50% to 60% of medications as prescribed despite evidence that medical therapy prevents death and improves quality of life.3   Knowledge deficits and poor understanding of drug label directions often result in medication errors initiated by patients. 

How to reduce medication errors by patients:

  1. Decrease medication knowledge deficits.  Review with patients in plain language what medications were prescribed, how to take them, discuss side effects and address concerns regarding drug interactions and cost.  Use visuals and show me techniques to ensure patient understanding.  Enlist the help of the PCP and pharmacist for additional education.
  2. 2.   An accurate medication list that includes discharge medications and/or chronic care medications is essential.  Learn how to take an accurate medication history.    Use clear communication techniques during conversations with patients.  Provide patient and PCP with discharge medication list.   
  3. Monitor for medication adherence.  Ask patients to bring in all of their medications or contact pharmacies for information on most recent refill dates.  Evaluate and address medication knowledge deficits.  Medication reminders, automatic med refills, medication home delivery, assistance of family members or home care services can be utilized to improve adherence.  Call recently discharged patients to ensure they are taking prescribed medications and chronic care medications. 

Stephanie Wilborne, APRN  Clear & Simple Patient Education/ Tools for Chronic Disease Management

1 National Coordinating Council for Medication Error Reporting and Prevention:

2Anderson, Pamela, and Terri Townsend. "Medication errors: Don't let them happen to you." American Nurse Today 5.3 (2010): 23-27:

3 Bosworth, Hayden, Bradi Granger, Stephen Kimmel, Larry Liu, John Musaus, William Shrank, Elizabeth Buono, Karen Weiss, Christopher Granger, Phill Mendys, Ralph Brindis, Rebecca Burkholder, Susan Czajkowski, Jodi Daniel, Inger Ekman, Michael Ho, and Mimi Johnson. "Medication adherence: A call for action." American Heart Journal 162.3 (2011): 412-424. Print.

4 Preventing Medication Errors: Quality Chasm Series Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors

Topics: reduce medication errors, medication errors, employment, hispanic nurse, ethnic, diverse, hispanic, black nurse, nurse, nurses, medication

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