Nursing

Pharmacology
Teri Capriotti

Basic Concepts to Prevent Medication

Calculation Errors

A landmark report “To Err is Human” from the

National Academy of Sciences Institute of
Medicine revealed that 7% of hospitalized patients
experience a medication error each year
(Springhouse Corporation, 2001a). Medication admin-
istration is a critical skill of the professional nurse,
who must understand and follow various steps in the
drug administration process to assure patient safety.
The nurse must be proficient in medication dosage
calculation to safely administer drugs. However, many
medical-surgical nurses experience difficulty when
calculating drug dosages. One study revealed that
56% of nurses could not calculate medication dosages
to a 90% proficiency rate. In addition, nurses made sig-
nificantly more errors in calculating intravenous drug
dosages as compared to oral, intramuscular, or sub-
cutaneous drug dosages (Ashby, 1997).
For the nurse to compute the correct dosage of a
medication, first the prescriber must write out the
order legibly. Poor handwriting has been cited as the
primary cause in 15% of medication error incidents
(Springhouse Corporation, 2001a). It is advisable for
prescribers to always clearly print medication orders
in capital letters. Many clinical settings have estab-
lished computerized prescription systems which have
eliminated the problem of illegible handwriting.
At times, verbal prescription orders are given to a
nurse, by word of mouth or per telephone. Because
these orders may be transcribed inaccurately, dosage
errors can occur. In clinical settings, verbal orders
should be discouraged due to this risk. If the pre-
scriber has no choice but to give a verbal order, he or
she should sign the order as soon as possible.
A misinterpreted decimal point is also a common
problem which can cause medication dosage errors. If
a dosage of a drug is less than zero and documented
as a decimal, a zero should precede the decimal point
Teri Capriotti, DO, MSN, CRNP, is a Clinical Assistant Professor,
Villanova University, College of Nursing, Villanova, PA.
for clarity (Karch & Karch, 2001) (see Figure 1).
Conversely, the prescriber should not place a decimal
point and zero after a whole number. If the decimal
point goes unnoticed by the transcriber or nurse, the
zero then acts to mistakenly multiply the dose ten
times (Karch & Karch, 2001) (see Figure 2).
Abbreviations in medication orders can easily be
misinterpreted. Abbreviations vary in different insti-
tutions and cause confusion. Whenever possible, the
words in a medication order should be clearly written
out. For example, words such as units, micrograms,
milligrams, every day, or every other day are preferable
to abbreviations for these words (Springhouse
Corporation, 2001b) (see Figure 3). Abbreviation of
terms within the metric system can be difficult to
decipher if handwritten. Whenever possible, metric
units should be written out as words. For an example
of possible misinterpretations of abbreviations of met-
ric units, see Figure 4.
The nurse needs to avoid distractions when cal-
culating, dispensing, and administering medications.
If one nurse is designated as the “medication nurse,”
this nurse should be identified clearly so others on
the unit will not interrupt or distract the nurse during
the task.
Lastly, the nurse who is administering a medica-
tion needs to follow the “5 Rights” of medication dos-
ing. If followed, this step-by-step process can decrease
chances for medication error. The nurse needs to be
sure that the right drug is being given to the right
patient, at the right time, at the right dose, per the right
route. The nurse should compare the medication
administration record with the label on the drug to be
administered at least three separate times: once when
obtaining the medication from the medication cart,
then upon opening the medication, and finally at the
bedside of the patient. After confirming each of the
above rights, the nurse should ask “Is there any rea-
son not to give this patient this drug?” (McGovern,
1988).
The nurse should have a drug reference guide
available on the medication cart. The patient’s med-
ications should “make sense” to the nurse. If a nurse

62 MEDSURG Nursing—February 2004—Vol. 13/No. 1

 Figure 1. suspects that something is wrong with a medication
Misinterpreted Decimal Point order, the nurse must question the prescriber about it.
Additionally, the nurse should be aware of the indica-
Rx Lorazepam 0.5 mg po q 6h prn anxiety tions and possible adverse reactions of the drug being
administered (Springhouse Corporation, 2001b).
is preferable to
With respect to medications, the nurse should
Rx Lorazepam .5 mg po q 6h prn anxiety assess a patient holistically. A nurse should ask the
following questions: What is the name of the patient?
Rationale: When written as lorazepam .5 mg, this can Does the armband on the patient confirm this name?
be easily misread as lorazepam 5 mg if the decimal Does this medication relate to the patient’s diagnosis
point is not accentuated. A zero in front of a “naked” and lab results? Does the patient have any allergies? Is
decimal point can help avoid this mistake. the patient on any prescription medication, herbal
preparation, or over-the-counter drug which could
interact with this drug? What are the possible adverse
Figure 2. effects to assess with regard to this medication?
Unnoticed Decimal Point (Springhouse Corporation, 2001b).
After administering the medication, the nurse
Rx Morphine sulfate 10 mg IM q 6h prn severe pain should watch the patient take the full dose of the med-
ication. At times, this may require that the nurse con-
is preferable to firm that the medication was swallowed by an oral
assessment. Older adults frequently have difficulty
Rx Morphine sulfate 10.0 mg IM q 6 h prn severe pain
swallowing some medications due to dry mouth, and
Rationale: If the decimal point in the second example they may need some vehicle such as apple sauce to
should go unnoticed, the dose of the drug adminis- stimulate salivation and enhance swallowing.
tered will be ten times indicated (for example, 100 mg If the patient experiences an adverse reaction to a
of morphine will be given instead of 10 mg). To avoid medication, this should be observed, reported, and
this kind of error, do not place a decimal and zero documented promptly. If a reaction occurs, the nurse
after whole numbers. should remain with the patient, monitor vital signs fre-
quently, and contact appropriate health care
providers immediately. An incident report should be
Figure 3. completed whenever an adverse reaction to a med-
Abbreviations ication occurs or if the nurse makes a medication
error. This document can legally safeguard the nurse
Rx 400 units vitamin D po every other day for the future. An incident report identifies the patient
is preferable to and witnesses, and provides an objective description
of the event and/or adverse reaction. No statements
Rx 400 U vitamin D po qod which indicate opinion, assumptions, or blame should
be part of an incident report (Springhouse
Rationale: The prescription in the first example is Corporation, 2001b).
easier to understand because words are fully
explained and not left to interpretation. Basic Principles of Calculating Drug Dosages
The nurse who administers medication needs
some basic mathematical skills such as knowledge of
Figure 4. the metric system, proportions, and ratios. The nurse
Standard Abbreviations for Metric Units Which must be able to accurately convert different base
Are Confusing if Handwritten units within the metric system (Hutton, 2003). The
prefixes are key to understanding how to properly
convert within the metric system (see Figure 5.) To
milligram (mg)
assess knowledge regarding conversions within the
metric system, the nurse should be able to calculate
problems in Figure 6.
microgram (ug) More than 1 in 6 medication errors involve errors
of calculation (Lesar, Briceland, & Stein, 1997). If the
drug is not available as a prepackaged unit dose from
the pharmacy, a calculator is useful when the nurse
nanogram (ng) needs to determine a medication dosage. If the nurse
uses paper and pencil to calculate a dosage, double
checking the math with another nurse is strongly
Rationale: Best to write out whole words of the
advised. The nurse can also verify the calculated dose
above metric units rather than abbreviate words with the pharmacist. According to Hutton (2003), the
because handwritten unit abbreviations can be mis- following is a simple mathematical formula which can
taken for each other. be used for most medication dose calculations:
What you want / What you have x What it is in

MEDSURG Nursing—February 2004—Vol. 13/No. 1 63

 Figure 5.
Common Units of the Metric System and Their Relationship to Base Units

Milli Micro Nano

Kilo (Base divided (Base divided by (Base divided by
(Base x 1,000) Base Unit by 1,000) 1,000,000) 1,000,000,000)

Kilogram (kg) Gram (g) Milligram (mg) Microgram (ug) Nanogram (ng)
Kilometer (km)
Meter (m) Millimeter (mm) Micrometer or
micron (um)
Liter (l) Milliliter (ml)

1 kilogram 1,000 grams 1,000,000 milligrams 1 x 109 micrograms 1 x 1012 nanograms

or 1 x 106 mg

Source: Hutton (2003)

Before calculation, conversion of metric units is nec- Figure 6.

essary to keep units of the numerator and denomina-
tor the same if units are dissimilar.
Example
Ampicillin 125 mg po q 4 hr is prescribed. A bot-
tle of ampicillin suspension contains 250 mg in 5 ml.
What volume should be given to the patient?
To calculate the volume of ampicillin to adminis-
ter to the patient, the nurse should use the above for-
mula as follows:
What you want (125 mg ) / What you have (250 mg)
x What it is in (5 ml)
125/250 x 5 ml
0.5 x 5 ml = 2.5 ml
In order to administer 125 mg of ampicillin, the
nurse should give 2.5 ml of the ampicillin suspension
from the above bottle.
Example
A patient is to receive 2 grams of neomycin. The
nurse has 500 mg tablets available. How many of
these tablets should be administered?
Because the nurse is dealing with different metric
base units, and the numerator and denominator must
have the same units, grams must be converted to mil-
ligrams first.
2 grams = 2,000 mg
What you want (2,000 mg) / What you have (500
mg) x What it is in (not applicable)
2,000 mg/500 mg = 4
The nurse needs to administer four tablets of
neomycin.
Example
A patient must receive 250 micrograms of digox-
in once every morning. The nurse has 0.125 mg
tablets available. How many tablets should be
administered?
Because there are two different metric base units,
milligrams must be converted to micrograms first.
0.125 mg = 125 micrograms
What you want (250 micrograms) / What you have
(125 micrograms) x What it is in (not applicable)
Refer to Figure 5 to Convert the Following Units
1. 0.1 g = how many milligrams?
2. 0.25 micrograms = how many nanograms?
3. 0.05 liters = how many milliliters?
4. 1,525 micrograms = how many milligrams?
5. 750 milligrams = how many grams?
Answers: 1) 100 mg; 2) 250 nanograms;
3) 50 milliliters; 4) 1.525 mg; 5) 0.75 grams
250/125 = 2 tablets
The nurse should administer two tablets of the
above digoxin to the patient.
Example
A postoperative patient needs 75 mg of hydrox-
yzine IM q 3-4 hr prn nausea. A vial of hydroxyzine
contains 100 mg/2 ml. How many ml should the
nurse administer?
No conversion of metric units needed; both are
the same.
What you want (75 mg) / What you have (100 mg)
x What it is in (2 ml)
75/100 x 2 = 0.75 x 2 = 1.5 ml
The nurse should administer 1.5 ml and discard
the remainder.
Example
A patient needs 12,000 units of heparin subcuta-
neously injected q 12 hours to prevent deep vein
thrombosis. A vial of heparin contains 40,000 units/
ml. How much heparin should be administered?
No conversion of metric units needed here.
What you want (12,000 units) / What you have
(40,000 units) x What it is in (1 ml)
12,000/40,000 x 1 = 0.3 ml
Intravenous Solutions and Drug Dosages
Some medications must be administered by the
intravenous route to ensure rapid delivery.

64 MEDSURG Nursing—February 2004—Vol. 13/No. 1

Medication orders seldom specify the infusion rate or
the number of milliliters per hour to be infused. Most
medication orders indicate an infusion of a specific
intravenous solution over a number of total hours.
Nurses must determine this rate of infusion based on
the dosage prescribed and information about the con-
centration of medication in the intravenous solution.
As noted previously, a method for calculating the
amount of medication to administer is to divide the
amount of drug you want by the amount of drug you
have on hand (Macmillan, 2000). At times, intra-
venous drug dosing should be calculated according to
the weight of the patient (for example, administer
dopamine at 5 micrograms/kg/minute). The nurse
must compute the dosage of drug based on the weight
of the patient in kilograms. When using body weight in
medication calculations, it is important for the nurse to
remember that 1 kg = 2.2 lbs. A calculator is recom-
mended as basic equipment for the nurse who must
perform these kinds of computations frequently.
Computerized systems which can calculate the
dosages are prevalent within critical care settings
where this type of intravenous dosing is common.
However, the nurse should understand the mathemat-
ics involved in performing intravenous drug calcula-
tions because computerized systems are not always
accessible.
Nurses in critical care settings must be familiar
with the variety of ways dosages are described. The
nurse should understand how to convert and deter-
mine equivalent dosages with orders that contain such
units as micrograms/minute, micrograms/kg/minute,
milligrams/hour, or milligrams/day. For many intra-
venous drugs, an infusion pump may be used which
requires a pump setting in any of the above units.
Alternatively, without an infusion pump, a drip factor
must be considered with intravenous solutions. This
factor indicates the number of drops in one milliliter
of intravenous solution and must be understood to
set up an IV drip apparatus (Guiliano, Richards, &
Kaye, 1993).
Example
The nurse is given an order to run 1,000 ml IV
D5W and 45% NaCl over 6 hours. The drip factor is
10 drops/ml. How many drops per minute and how
many milliliters per hour should be administered?
What you want to administer: 1,000 ml/6 hours =
167 ml/hour
What you have: 1,000 ml intravenous with a drip
factor of 10 drops per ml
How you need to administer this:
167 ml/hour x 10 drops/ml = 1,670 drops per hour
1,670 drops/hour = how many drops/minute
1,670 drops/60 minutes = how many drops/minute
This is equivalent to approximately 28 drops per
minute.
Example
A patient weighs 108 pounds and needs to
receive 6 micrograms/kg/minute of dobutamine.
The intravenous solution from the pharmacy con-
MEDSURG Nursing—February 2004—Vol. 13/No. 1
tains 250 mg of dobutamine in 250 ml D5W. If the
drip factor is 60 drops/ml, how many microdrops
per minute and how many milliliters per hour
should be administered?
The patient’s weight must be converted to kg.
Approximately 1 kg = 2.2 pounds
108 lbs / x kg = 2.2 lbs/1 kg
108/2.2 = 49 kg
What you want:
6 micrograms x 49 kg/minute of dobutamine
294 micrograms/minute of dobutamine
294 micrograms/minute = how many micro-
grams/hour
294 x 60 = 17,640 micrograms/hour
Converting micrograms to milligrams: 17.64 mil-
ligrams/hour = approximately 18 mg/hr
What you have:
250 mg dobutamine in 250 ml D5W
1 mg/1 ml
18 mg/18 ml
Drip rate = 18 ml/hour
At 60 drops/ml, this equals 1,080 drops/hour or 18
drops/minute
Conclusion
Prescription of medication may be one of the
most critical skills of the physician, and administra-
tion of medication may be the most crucial skill of the
nurse. However, medication calculation errors are
commonplace and often life-threatening to the
patient. To safeguard against medication errors, the
nurse and physician should periodically review and
update their medication calculation skills. Some stan-
dard mathematical formulas for medication dosage
calculation are available, and the nurse is in the per-
fect position to act as a gatekeeper to proper medica-
tion administration. To decrease medication errors,
periodic review of dosage calculation math skills
should be a key component of continuing education
for all professionals.■
References
Ashby, D.A. (1997). Medication calculation skills of the medical-
surgical nurse. MEDSURG Nursing, 6(2), 90-94.
Guiliano, K.K., Richards, N., & Kaye, W. (1993, December). A new
strategy for calculating medication infusion rates. Critical Care
Nurse, 77-81.
Hutton, M. (2003). Calculations for new prescribers. Nursing Standard,
17(25), 47-52.
Karch, A.M., & Karch, F.E. (2001). The naked decimal point. American
Journal of Nursing, 101(12), 22.
Lesar, T.S., Briceland, L., & Stein, D.S. (1997). Factors related to errors
in medication prescribing. Journal of the American Medical
Association, 277(4), 312-317.
McGovern, K. (1988). Ten golden rules for administering drugs safely.
Nursing, 18(8), 34-42.
Macmillan, P. (2000). Calculating medication dosages. Critical Care
Nurse, 20(6), 17-19.
Springhouse Corporation. Expert Nurse Video Series. (2001a).
Protecting patients from medical errors. [Film]. Philadelphia:
Springhouse Corporation.
Springhouse Corporation. Expert Nurse Video Series. (2001b).
Preventing medication errors. [Film]. Philadelphia: Springhouse
Corporation.
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