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Medication Error Paper

Pamela Chong
University of South Florida

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The main purpose of providing healthcare to our patients is to do no harm yet medical
errors still happen, some ending in serious consequences. A medication error refers to any
preventable event that may cause or lead to inappropriate medication use or patient harm while
the medication is in the control of the healthcare professional, patient, or consumer (Kim &
Bates, 2013). Medication errors may vary from harmless to lethal, depending on what type of
error was made. Some of the most common medication errors do not always result in serious
harm to the patient, therefore may not be seen as clinically significant. Other errors, such as
giving the wrong medication or dose may result in significant harm to the patient, and in some
cases, death. There are several methods in practice to help healthcare professionals prevent
medication errors and reduce harm. Human error is the number one reason for medication errors,
and it is possible that one day I will also make a mistake. I will take extra precautions when
administering medication to ensure I give the best care to my patients, and prevent medication
errors.
Medication errors harm 1.5 million and kill thousands of people in the United States
annually (Kim & Bates, 2013). These errors are associated with an increased length and cost of
hospital stay, patient disability, and death. Among all errors, the majority occur at nurse
administration (Redley, & Botti, 2013). With the implementation of electronic medical systems,
some of the more serious errors, such as wrong patient, are seen significantly less often.
In the hospital setting, one of the most common medication errors made by nurses is
wrong administration time. Despite the frequent error, many believe that the significance of this
error is clinically irrelevant. In a particular study, Administration time errors were defined as
medication administration (actual intake) occurring more than one hour before or after the
prescribed time. (Teunissesn, Bos, Pot, Pluim, & Kramers, 2013). The busy, hospital

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environment is considered to be a major reason why drugs are not always administered at the
time in which they are scheduled. In a separate study, the average number of patients one nurse
was caring for was eighteen. In addition to this, the majority of drug administration is
synchronized across the ward, making it nearly impossible to administer all the drugs to the
patients at the correct time (Kim & Bates, 2013). Due to the belief that time administration errors
were clinically insignificant, a group of researchers wanted to explore the theory to see if there
was truth behind the belief. In their study, they found that time errors were potentially relevant in
only two cases. Most time errors occurred with medications that had the potential to interact with
food or other medications (Teunissesn, et al., 2013). They found that the previous consensus was
likely to be true about the clinical relevance of correct time administration. Despite this, clinical
consequences may still occur as a result, therefore a reduction of errors in time administration is
still favorable (Teunissesn, et al., 2013).
Ideally, we want to prevent all medication errors, even if the error is not likely to harm
the patient. Since many of the time administration errors are related to the heavy workload of
nurses, the way to alleviate the problem would be to reduce the patient load of each nurse. This
requires a systematic solution, and is a responsibility of the hospital administration rather than
the individual nurse (Kim & Bates, 2013). The correlation between nursing work environment
and medication safety is significant. Nurses can provide safer patient care through quality
management and work environment transformation (Kim & Bates, 2013). Decreased
medication errors and increased error reporting have resulted from redesigned work processes
including workflow, documentation, standardized procedures, and interdisciplinary
communication (Kim & Bates, 2013).

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As I start my career as a nurse, I am fearful of making medication errors, especially those

that may be detrimental to the patient. One of the main errors I am afraid of making, is giving the
wrong dose to a patient. Wrong dose may have extremely harmful effects, especially with drugs
that require meticulous preparation, such as insulin. This being said, I will always follow the five
rights of medication administration to prevent errors. These rights include right patient, right
medication, right route, right time, and right dose. Double checking all of these rights is an
excellent way to prevent medication errors. In the case of drawing up medication with a syringe,
I will be sure to double check with another nurse that I have drawn up the correct dose. If I am
mixing insulin, I will show another nurse after I draw up each type of insulin, and be sure to
show them the vile that I have drawn from. The majority of my fear involves injections, or
medications that I have to prepare myself yet I will always be careful, and double check orders
no matter what route I am administering a medication.
Medication errors may occur at any stage in the production, prescription, or
administration of the drug yet the majority of errors are associated with nurse administration.
Certain errors made may go unnoticed and others may result in severe harm or even death to the
patient involved. Although some of the most common errors made, such as wrong administration
time, usually do not result in harm to the patient, adverse reactions are still possible, therefore it
is important to prevent these types of errors. Thankfully, with the help of electronic medical
systems, the more severe medication errors, such as giving a medication to the wrong patient, are
seen far less often. Since errors are associated with increased patient load, one way to reduce
nurse errors would be to reduce their workload. When I begin working as a novice nurse I will do
everything in my power to avoid medication errors, as I understand the major responsibility of
medication administration. If I ever have questions about any of the medication rights, or am

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unsure of a particular medication, I will be sure to ask another, more experienced nurse that may
be able to help.

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References
Kim, J., & Bates, D. (2013). Medication administration errors by nurses: adherence to guidelines.
Journal of Clinical Nursing, 22(3/4), 590-598. doi:10.1111/j.1365-2702.2012.04344.x
Redley, B. & Botti, M. (2013). Reported medication errors after introducting an electronic
medication management system. Journal Of Clinical Nursing, 22(3/4), 579-589.
doi:10.1111/j.1365-2702.2012.04326.x
Teunissesn, R., Bos, J., Pot, H., Pluim, M. & Kramers, C. (2013). Clinical relevance of and risk
factors associated with medication administration time errors. American Journal of
Health-System Pharmacy,70(12), 1052-1056. doi:10.2146/ajhp120247