PATI ENT SAF ET Y
Simple steps to reduce medication errors
By Ruby Z. Chu, MSN/Ed, RN, CCRN
FRONTLINE NURSES spend
much of their time administering
medications. Accurate and safe
Downloaded from https://journals.lww.com/nursing by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3rL6MiOW0w/NSp5U9nftn32XSqrP08wWxlAOPKFpk7uU= on 03/21/2020
medication administration depends
on nurses’ pharmacologic knowl-
edge, decision making, and critical
thinking skills.
In a fast-paced healthcare envi-
ronment, administering medica-
tions is a high-risk nursing task.
Medication errors may occur dur-
ing any phase of the medication
process: prescribing, transcribing,
dispensing, administering, moni-
toring, and reporting. This article
focuses on nurses’ roles in medica-
tion administration. Start by con-
sidering the effects of medication
errors.
Consequences of errors
Medication errors can have serious
and costly consequences, such as
increased patient lengths of stay,
additional medical interventions,
serious harm, or even death.
According to a new study con-
ducted at Johns Hopkins Univer-
sity, medical errors have become
the third leading cause of death
in the United States, claiming
250,000 lives annually.1
For nurses, making a medication
error is an emotionally traumatic
experience that undermines their
self-esteem and confidence to func-
tion in the workplace.2 Jones and
Treiber used quantitative and qual-
itative questionnaires to survey 202
nurses; 158 claimed they’d made
medication errors.2 Qualitative
data analysis showed several
themes. For instance, making an
error makes nurses feel depressed,
guilty, embarrassed, regretful, and
fearful about providing safe care
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and violating the patient’s trust.
Nurses involved in medication
errors experience moral distress
and want to leave nursing
practice.2
Why aren’t errors reported?
Reporting medication errors is
problematic due to fears of reprisal,
intimidation, or disciplinary
actions.3 Oshikoya et al. surveyed
pediatric nurses working in a pub-
lic hospital to examine their experi-
ence with medication administration
errors.3 Structured questionnaires
were distributed to 75 nurses, and
50 nurses completed them. The
major factors contributing to errors
were found to be increased work-
load (26.2%) and failure to check
the drug dosing (12.24%). Barriers
to reporting medication errors
included fear of punishment for
committing the error (11.22%),
lack of a standard reporting system
(13.26%), and fear of punishment
for reporting the errors (27%). As a
result, 34% of medication errors
weren’t reported by nurses.
Nurses may fear that reporting
errors can increase the chance of
litigation. A qualitative study by
Hartnell et al. identified barriers to
medication error reporting.4
Results were categorized into
themes: inconvenience of report-
ing, professional identification,
missing information, ineffective
organizational system, and fear of
punishment. These barriers can be
overcome by making the reporting
process easier, using proper com-
munication, and providing educa-
tion on reporting. Encouraging
staff to report an error may eventu-
ally reduce the incidence of
medication errors and enhance
patient safety.
Contributing factors
Nurses who don’t follow the five
rights (right drug, right patient,
right dose, right time, right route)
of medication administration can
contribute to medication errors.
Deficits in pharmacologic knowl-
edge, miscalculations, distractions,
increased workloads, and fatigue
are common reasons why the five
rights aren’t always followed.
Because drug calculations can be
complex, proficiency in mathemati-
cal skills is required for safe drug
administration.5,6 Fluid bolus and
tablet formulations are generally
easy to calculate, but continuous
I.V. infusions of high-risk medica-
tions such as heparin, insulin, and
vasopressors involve complex
calculations.
Understanding decimals is
important when performing dosage
calculations. Misplacing or omit-
ting decimals can result in serious
calculation errors.7
During drug preparation, nurses
can be distracted when they’re
interrupted. Research has revealed
that distractions contribute to med-
ication errors.8-10 In a study by
Esqué Ruiz et al., nurses reported
65.4% of medication errors
and 59% of them were due to
distractions.9
Increased patient workloads may
predispose nurses to take shortcuts
and fail to follow drug administra-
tion procedures, such as verifying
patient identification. In Kim and
Bates’ observational study of
293 nurses, only 6.5% checked
their patients’ wristbands and
August l Nursing2016 l 63
PATI ENT SAF ET Y
3.5% asked to confirm patients’
names.11
Lack of adequate staffing
increases workload and fatigue,
which negatively affect the nurses’
work performance related to drug
administration. When nurses are
both distracted and physically
exhausted, the risk of drug dose
miscalculation increases.10
Preventing missteps
Proficiency in drug calculations is
essential for safe medication
administration. Having sound basic
mathematical skills and performing
accurate drug calculations can sig-
nificantly minimize medication
errors. Nurse educators play an
important role by having an educa-
tion plan in place to ensure nurses
maintain their proficiency in medi-
cation calculation. Simulated prac-
tice in medication administration
can benefit nurses without the risk
of harm to patients.
Nurses must improve their
pharmacologic knowledge and keep
up-to-date about new drugs.5 Ongo-
ing medication competency must be
maintained. Pharmacologic continu-
ing education updates nurses about
the safe use of new drugs, including
appropriate indications and dos-
ages, proper administration, drug
actions, contraindications to use,
drug-drug interactions, potential
adverse drug reactions, patient
monitoring, patient teaching, and
documentation.
Interventions to decrease distrac-
tions can enhance patient safety.
Some healthcare facilities have
implemented the sterile cockpit rule,
which means eliminating distrac-
tions during medication prepara-
tion to avoid medication errors.
This strategy was developed by the
airline industry in the 1980s to
preserve safety in the cockpit area
64 l Nursing2016 l Volume 46, Number 8
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
by preventing nonessential activi-
ties or conversations during the
critical phase of flight. In a study
by Fore et al., the rate of medica-
tion errors dropped by 42.78%
when this rule was in place.12
Because nurses tend to be in con-
stant communication with their
patients and the healthcare team,
the sterile cockpit rule may be
challenging to implement. A
“do not disturb” or “quiet zone”
sign in the medication prepara-
tion area can help minimize
distractions.
To safeguard against medication
errors, nurses must implement the
proper procedures for medication
administration, including at least
these five rights: right patient,
drug, dose, route, and time. In
addition, they must complete
accurate documentation once the
patient receives the medication.11,13
Failure to record the medication
administered increases the risk that
the patient will receive another
dose. Nurses should be cautioned
not to document the dose before
the medication is given because,
for one reason or another, the
patient may not receive the medi-
cation at all or might receive it at a
different time than documented.
Patients need to be well
informed of medications’ therapeu-
tic effects, potential adverse reac-
tions, and desired outcomes.
Evaluating the effect of certain
medications is crucial to ensure the
patient has responded to the medi-
cation; for example, high blood
glucose levels may be treated with
sliding scale insulin dosages. The
patient’s blood glucose levels must
be closely monitored to ensure
they’re within the desired thera-
peutic range, and the patient must
be closely monitored for and
taught to report adverse reactions,
such as signs and symptoms of
hypoglycemia.
When administering an analge-
sic, the nurse must first assess the
patient’s pain level, administer the
analgesic drug, and then monitor
for adverse reactions and evaluate
and document the therapeutic
response. If the desired effect isn’t
achieved, the patient may have
received an inadequate dose or may
require a different analgesic for
pain control.
Many medications can be admin-
istered via different routes, such as
oral or I.V., increasing the possibil-
ity of confusion. Some forms of
medications, such as enteric-coated
medications intended to prevent
stomach irritation, shouldn’t be
crushed. Nurses should frequently
double-check to ensure they’re
administering medications via the
correct route and in the prescribed
form.
Providers may prescribe specific
I.V. dosing regimens based on their
own preference and previous expe-
rience, institutional standards, and
smart pump setup. For example,
dopamine infusion titrations may
be prescribed using microgram/
kilogram/minute dosages or micro-
gram/minute dosages to maintain
the mean arterial pressure above
65 mm Hg.
Using multiple dosing methods
for the same drug can be confus-
ing, increasing the risk of errors.14
Standardizing the dosing method
for I.V. medications such as epi-
nephrine, midazolam, and nitro-
glycerine infusions in the ICU
could minimize dosing errors.15
Referring to a list of high-alert
drugs can help safeguard nurses
from making medication errors.16
Understanding the placement of
decimals is crucial; for example,
0.20 mg is 10 times greater than
www.Nursing2016.com
0.02 mg. Nurses need to have a
clear idea of decimal placement
and values to avoid calculation
errors.7
Technology such as smart
pumps and bar code-assisted
medication administration
(BCMA) can help to decrease
drug-dosing errors when used
appropriately. Nurses using BCMA
scan the patient wristband and
medication codes before adminis-
tering medications. In one study,
BCMA decreased wrong dosage
errors by 90.4%, medication
administration errors by 80.7%,
and medications lacking prescrip-
tions by 72.4%.17
I.V. smart pumps have error-
prevention software, drug libraries,
and dosing limits that give an
alert when the dosing is out of
range.15,18 Manrique-Rodríguez et
al. studied the benefits of using I.V.
smart pumps in pediatric ICU
patients.18 A total of 624,252 infu-
sions were initiated, and 486,875
medications were programmed
through the smart pump drug
library. User safety software com-
pliance was 78%. Using the smart
pump device resulted in 92 cases
of programming errors being inter-
cepted; 84% of these medications
were for pain, sedation, cardiac
conditions, and infections. Using
smart pumps enhanced patient
safety.
Reporting medication errors
helps identify failures in medica-
tion processes and may help to
prevent further incidents. When
medication errors are reported, risk
managers use the information to
better understand the root causes
and develop policies and proce-
dures to prevent future patient
harm. When errors are reported
voluntarily in a guilt-free, blame-
free system, a proper investigation
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can be performed and practice can
be improved.9,13
Many hospitals use electronic
reporting systems, which let the
individual involved in a medication
error provide information electron-
ically. Managers and quality risk
management are then notified
electronically.19 The key benefits
of the system include increased
reporting of medication errors,
identifying close-call events (errors
that are identified and corrected
before reaching the patient), and
improved tracking, which is
followed by action.19,20 When
data from medication errors are
shared, an action plan can be
developed, which may reduce
further errors.
Stepping up
Medication errors are preventable
events. Safe medication practices,
adequate resources, a work envi-
ronment free from interruptions,
and a nonpunitive approach
to error reporting should be
encouraged. ■
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Ruby Z. Chu is a clinical nurse educator at Michael
E. DeBakey VA Medical Center in Houston, Tex.
The author has disclosed no fi nancial relationships
related to this article.
DOI-10.1097/01.NURSE.0000484977.05034.9c
August l Nursing2016 l 65