Running head: MEDICATION ERRORS AND THEIR PREVENTION

Medication Errors and Their Prevention

Kristine Martin
University of South Florida

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According to the U.S. Food and Drug administration, medication errors cause at least
one death every day and injure approximately 1.3 million people annually in the United States
(Medication Error Reports, 2009.) A medication error can occur at any point in the distribution
system: prescribing, dispensing, administering and/or monitoring. Medication errors are
preventable and can be caught and corrected by several members of the medical team including
the physician, pharmacist, and the nurse. However, being that the nurse is the one to administer
the medication, the blame of a medication error often falls upon our shoulders. There are several
integrating factors that lead to medication errors and it is important that we as nurses make sure
we take every possible step to ensure the safety of our patients.
It is no secret that nurses are unable to spend copious amounts of time with a single
patient. Nurses are often rushed throughout their day in order to meet all their patients needs and
keep up with documentation. Because nurses have an overwhelming number of tasks to do in a
limited time, it can be easy to overlook steps that need to be taken prior to medication
administration. Several medications require certain values to be assessed prior to administration
in order to make sure the medication can be safely administered. A nurse who is rushing could
forget to check a significant value prior to administration and give the patient a medication that
should have been held, resulting in a medication error. Although nurses have a busy schedule,
there is no exception to checking these values prior to administration and is always a necessary
step despite the time crunch. In the long run, it will take more time out of the nurses day to
correct the error than it would have taken to check the value in the first place.
Patient identification is a key factor in preventing medication error. It is important to use
two forms of identification, commonly name and date of birth, to identify the patient prior to
administering medications. A study by Ashcroft, Cooke, Keers and Williams (2013) found that

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patient misidentification is a large contributor to medication errors. In facilities with a large

number of patients, especially those with two patients per room, it can be hard to keep track of
who is who, thus leading to a potential medication error. With the elderly and confused patients,
confirming the patients identity with their identification band is particularly important as these
patients may not be orientated to first person and forget who they are or claim to be someone
else. The authors also stated, however, that continuously asking the patient for their name and
birthday can undermine the nurse-patient relationship (Ashcroft, Cooke, Keers and Williams,
2013). Although this may present a challenge, the nurse should explain to the patient they must
keep re-identifying their patient to make sure they are giving the correct medications and are
providing the safest care possible.
Another important aspect of preventing medication errors is to always check the patient
for allergies. This can be done by referring to the patients chart, looking at the patients allergy
band and asking the patient to state any allergies. Oftentimes the patients chart or allergy band
shows the incorrect allergy or that there is no allergy when that is not the case; therefore, it is
important to ask the patient to state their allergies to assure there will be no adverse reaction to
the medication.
Communication error can contribute to medication errors as well. If a miscommunication
occurs between the physician, pharmacist and nurse, this could potentiate a medication error. If
communicating over the phone, the nurse or pharmacist could have misheard the physicians
orders resulting in the incorrect medication, dose, route, or time of administration. It is essential
to always verify orders with another RN to prevent these types of errors. If an order is
questionable the RN must be confident to communicate their concerns with the physician to
determine if the orders are correct and safe to administer. Many times two or more medications

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will be ordered that are contraindicated in one another or are there are multiples of the same
medication. Communication is key between all members of the treatment team to provide safe
and efficient care.
Patient education is another important component in the prevention of medication errors.
The nurse should make sure the patient has a thorough understanding of his or her medication
regimen and any contraindications for their medication. It is particularly important to make sure
the elderly understand their medications because they are oftentimes taking multiple drugs at
once and could become confused as to which medication to take when. Providing patients with
printed out information and advising them to consult their pharmacist if they have are questions
are good tactics to prevent medication errors in the home setting.
Although there are an abundance of factors that contribute to medication errors, the topics
discussed above are commonly of blame. It is the nurses job to do everything in their power to
prevent medication errors despite their busy schedules. An article by Jan Bennet (2008) discusses
using the six rights to prevent medication errors. The six rights refer to: the right drug, to the
right patient, at the right time, in the right dose, by the right route and with the right
documentation. The method can be used to prevent a plethora of common medication errors.
Using this method, along with communicating with team members, correctly identifying patients
and allergies, and taking their time when reviewing values prior to administration, nurses can
prevent medication errors.

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References
Ashcroft, M. D., Cooke, J., Keers, N. R., Williams, D. S. (2013) Causes of Medication
Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative
Evidence. Drug Saftey. 36, 1045-1067. doi: 10.1007/s40264-013-0090-2
Bennet, J. (2008) Medication Errors: Managing the Risk. Long-Term Living, 5. Retrieved From:
http://eds.a.ebscohost.com/eds/detail/detail?vid=5&sid=080fc30f-76bf-493db2f9a9c0ae495971%40sessionmgr4003&hid=4111&bdata=JnNpdGU9ZWRzLWxpdmU
%3d#db=gnh&AN=124231
Medication Error Reports. (2009) U.S. Food and Drug Administration. Retrieved From:
http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm