MEDICATION ERRORS 1

Medication Errors

Jessica J. Yandle

University of South Florida, College of Nursing

Medication Errors

Each and every patient that is seen and cared for at a hospital is at the mercy of their

medical team to provide them quality care. Unfortunately, there are instances where one or more

people in that medical team may fail to follow all six rights of medication administration (right

patient, right medication, right dose, right time, right route, and right documentation) resulting in

a medication error. If this occurs, the patient is at risk for harmful effects, and even, potential

death. Due to the irresponsibility of nurses and providers, others have reaped the consequences.

It is estimated that upwards of 7,000 people in the US die annually from medication errors, while

many others suffer psychological and physical complications from medication errors (Tariq et

al., 2022). The harsh reality is that medication errors happen far too often. This paper will

discuss common medication errors, effects of those errors, as well as ways to prevent errors from

occurring in an attempt to highlight the importance of this topic and start reducing the amount of

medication errors.

Common Medication Errors

Three common medication errors include: mishearing drug orders when given by a

provider verbally or via the telephone, administering the wrong dose, and not giving a

medication within the right timeframe.

Mishearing Drug Orders

It is quite plausible how a nurse could mishear a provider’s medication order when given

verbally or via telephone as there are numerous medications that sound similarly. Misconstruing

verbal orders is common as medical professionals are culturally diverse and enunciate words

with different accents and dialects (Hendrickson, 2007) . Wearing masks in the operating room

provides a barrier to reading lips, which helps ensure the accuracy of interpreting orders. And,
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distractions can deter one from hearing the correct medication order (Hendrickson, 2007). Due to

the chances of verbal orders being misconstrued, these orders should be reserved for emergencies

only. But even with this reservation implemented, errors still occur.

Administering The Wrong Dose

Administering the wrong dose can cause a patient to be under-dosed or over-dosed. This

medication error is most likely to stem from receiving an incorrect prescription from a provider

(Tariq et al., 2022). The nurse may be at fault for this error as well. For example, a nurse could

remove too many or too few tablets of a medication from the pyxis. Or, a nurse may forget to cut

a tablet or pill that is required to be cut prior to administration.

Administering a Drug Outside The Prescribed Timeframe

Administering a drug outside the prescribed timeframe is the most commonly recorded

medication error. It is vital that a medication that has a narrow window be given at a particular

time to ensure proper therapeutic effects (“Wrong-Time,” 2018). However, when a nurse is

managing the care of several different patients, distractions may cause medications to be given

outside of their prescribed time window. Ultimately, distractions and forgetfulness are the cause

of this medication error.

Impact on Patients and/or Families

Mishearing verbal/telephone orders can cause a mishap to occur in any of the six

medication rights. The most severe cases are thought to stem from a patient receiving an

incorrect medication all together or being overdosed. An example of this could involve a nurse

interpreting an order for antithrombin as thrombin during surgery, and now the patient is at risk

for developing blood clots (“Start the,” 2020). Ultimately, the patient is at risk for developing

complications that ensue with what and how the medication was prescribed. And, if the patient
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becomes violently ill from that mistake, the family has to step in to make decisions and become a

caregiver for the patient.

Giving a patient the wrong dose of a medication can cause them to not receive

appropriate treatment for an illness or can cause them to receive too much of a treatment, causing

them possible harmful side effects. For example, if too much of anticoagulant is given, the

patient is at high risk for bleeding. However, it too little of an anticoagulant is given, the patient

may develop a clot such as a DVT that could progress as far as a pulmonary embolism. The

effects of this issue would be dependent on how significant of a wrong dose was administered.

Most medication errors resulting from administering a medication outside the allotted

time window are usually benign unless the medication is a high-alert medication (“Wrong-

Time,” 2018). In most cases, absorption of a drug can be affected if timing is neglected. For

example, a patient was supposed to receive a drug within thirty minutes of a meal but did not

receive the medication until two hours after eating a meal. Thus, GI upset could result.

Avoiding Medication Errors

To guarantee a nurse does not mishear a provider’s order, they should readback the order

to confirm the accuracy, they should spell the drug name back to the provider to avoid confusion

of another drug, and they should state each dose in single digits (“Start the,” 2020). To avoid

administering the wrong dose of a medication, the nurse should call the provider if the order does

not look appropriate and the nurse should perform the three necessary medication checks prior to

administering the medication. Lastly, to prevent administering medications outside the

prescribed timeframe, the nurse should plan ahead when starting their shift, they should take note

of any high-alert medications and administer those medications first, and consult with the charge
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nurse for help if too many distractions arise that may interfere with patients not receiving their

medications on time.

Impact on Students

As someone who is diligent and organized with their work, I know I will beware of

making medication errors throughout my career. However I am not naïve enough to discount the

fact that there may come a time where I catch myself in the act of making a medication error. I

just hope that I’m cognizant of my actions before they could cause potential harm to a patient.

My greatest fear is that I will not be able to always give medications in their prescribed

timeframe. I have seen this mistake occur in clinical and it is one that is difficult to avoid when

preoccupied with numerous distractions. However, in an attempt to prevent this from happening,

I will plan accordingly and write out high-alert medications for each patient on my report sheet. I

can also reach out to the charge nurse for help if I encounter too many distractions that may

cause my patients to not receive their medications in the appropriate time window. The biggest

way to combat this is to know of a “plan B” if distractions that could compromise patient care

arise. I also fear misinterpreting a telephone or verbal order, but now I know, that doing a simple

readback with the provider can protect the patient from potential harm.

Conclusion

Researching and writing this paper has made me painfully aware of the magnitude of

medication administration errors. A human error can cause one to lose their life. Thus,

administering medication should not be taken lightly, and a nurse should always implement

performing the three necessary medication checks and following all six rights of medication

administration. I would not claim that this paper has shifted my attitude regarding the task of

medication administration as I’ve always considered this topic with seriousness. However, this
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paper has enhanced my knowledge of more things that could go wrong and methods to combat

those things from going wrong. This paper has helped me demonstrate professional

accountability in clinical practice simply by understanding the negative consequences that could

result by negligence. Simple preemptive steps such as practicing medication administration

rights and practicing nursing interventions can prevent medication errors from occurring

(Mohanna et al., 2022).

References

Hendrickson T. (2007). Verbal medication orders in the OR. AORN Journal, 86(4), 626–629.

https://doi-org.ezproxy.hsc.usf.edu/10.1016/j.aorn.2007.04.002

Mohanna, Z., Kusljic, S., & Jarden, R. (2022). Investigation of interventions to reduce nurses’

medication errors in Adult Intensive Care Units: A systematic review. Australian Critical

Care, 35(4), 466–479. https://doi.org/10.1016/j.aucc.2021.05.012

Start the new year off right by preventing these top 10 medication errors and hazards. Institute

For Safe Medication Practices. (2020, January 16). Retrieved March 14, 2023, from

https://www.ismp.org/resources/start-new-year-right-preventing-these-top-10-

medication-errors-and-hazards

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022, July 3). Medication Dispensing

Errors and Prevention . Retrieved March 14, 2023, from

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

Wrong‐Time Error With High‐Alert Medication. (2018). AORN Journal, 107(4), 540–542.

https://doi-org.ezproxy.hsc.usf.edu/10.1002/aorn.12086