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Medication Administration Safety and Prevention

Danielle Giaritelli, SN
University of South Florida


Leading Causes of Medication Errors

Today, medication errors are the third leading cause of death in the United States
accounting for almost 400,000 deaths each year. Medication errors a common occurrence
of life threatening health care mistakes that affect patient care. These mistakes are a
worldwide problem, which have negative outcomes including increasing the amount of
mortality rates, extending the length of the patients hospital stay, and elevating the
patients costs. The amount of medication errors each year should be decreasing with
collaborative care of each health care worker doing their part in reducing the risk for
causing errors (James, 2013).
According to 54 studies conducted in May 2013, there were multiple reasons for
medication errors. The most common causes found in this study were slips and lapses. A
slip is a cause when a healthcare worker has failed to carry out their intended action like
forgetting to administer a medication by the end of their shift. A lapse is a cause when
they simply fail to do something because of forgetting or lack of paying attention to what
they needed to do. Because of how busy a nurse or physician can be, it is understandable
that forgetting to administer the med is the number one reason behind a medication error.
Other common causes from this study were inadequate communication through
prescriptions or documentation, pharmacy dispensing errors, and disruptions or
disturbances during medication administration (Keers,&Williams,&Cooke,&&&Ashcroft).
Verbal and telephone read back orders are a high risk for error because they arent
written down. The risk of the nurse writing down the wrong medication or hearing


something different than the provider ordered is likely because they are going off of what
they heard. Most facilities try to avoid telephone or verbal read back orders because of
the risk involved unless a case of emergency. Pharmacy dispensing errors can happen if
the wrong medication is in the pixis or they give the wrong medicine to the patient
directly from the pharmacy. Although the wrong medication may be placed in the pixis, it
is still whoever is getting the medication to verify they are pulling out the right
medication. If a nurse is returning a medication to the pixis or if they grabbed the wrong
medication, they might put it back in the wrong pocket potentially causing a future error
for the next nurse. Any type of distraction while administering or pulling medications is a
definite way to make an error. When a patients life is at stake, they deserve and need the
providers full attention, especially when it is giving their medications. If a provider is
distracted or interrupted by someone they may lose focus on the medication and give the
wrong one or forget to give one (Vaismoradi,&Jordan,&Turunen,&&&Bondas,&2014).
The incidences of medication errors each year is devastating, but also preventable.
Avoiding medication errors and taking every measure possible to prevent them is a
crucial part of patient safety and care. There are many different professions that take part
in a patients care and all can help prevent and reduce errors each year. Using inter
professional care is vital to patient safety and care by learning about their professions and
using collaborative care to treat.
Preventing Myself from Having Medication Errors
When thinking about how I can prevent myself from making medication errors
throughout my clinical practice, the six rights-right patient, right dose, right time, right


route, right medication, and right documentation-are the first thing that come to mind. I
learned the six rights in every class I have taken and have continued learning them in
every course. I realized early on how important they would be from the day I learned
them and throughout my whole nursing career. Using the six rights during my clinical
practice will help me prevent making medication errors because I will verify the
medication when pulling it, verify it again by scanning it into the computer, and making
sure it matches the MAR. Also verifying the patient by using two patient identifiers to
do so and scanning their wristband using the hospitals precautions that are already in
place. I understand the importance of being focused solely on my patient when giving
them their medications.
There are other interferences that can impede ones judgment that allow them to
make an error. Eliminating distractions like the television or people talking will allow me
to concentrate on what I am doing and making sure I keep my attention on the patient. I
want to make sure the patient understands the medicine they are getting and why, so
having their full attention will make this process easier and assuring that they know.
Using references to my advantage including Nursing Central and the Reference
Manual in Cerner will give me access to what the medication is, side effects, examples of
when to use the drug cautiously, and labs to look out for. Knowing the significance of
normal lab values of electrolytes, red blood cell counts, white blood cell counts, and other
necessary values are essential to medications because they can alter a decision of whether
or not to give a drug and ultimately prevent an error that could harm the patient.
There are multiple preventative measures that can be taken to reduce the risk of


medication errors done annually. Knowing the causes behind errors are extremely
helpful, because I know things I can do to prevent those specific causes. Also,
understanding my role as a nurse and what I can do each day to prevent errors and
practicing that way will be a fundamental part of preventing medication errors throughout
the rest of my career.