



Clinical Practicum
Final Prof. BSc.Nursing
Topic: Medicine Administration Error

Submitted To:
Ma'am Hafiza Saba Javed
Submitted By:
Rimsha Boota
Ayesha Sidiqa
Javaria Zafar
Shazza Akmal
Shuja-ur-Rehman
 


Sr no. Contents Page

no.

1 Case Scenario 2

2 Introduction 2

3 Objectives 4

4 Literature Review 4

5 Purpose 8

6 Causes 8

7 Ways to reduce medicine administration error 9

8 Recommendation 10

9 Conclusion 13

10 Reference 14

1|
 


Medicine Administration Errors:

Case scenario
The case that we choose to study was medication administration errors that occur most
frequently in the ward and these occupy most of the hospital acquired diseases.We was on
our clinical rotation in medical ward, preparing for medicine administration at 12:00 pm. The
senior nurses were busy in their work so much that one of the staff nurse use the already used
injection on another patient.The incidence was acknowledged by the client's attendants, when
they told the nurse that , the syringe that they brought for injection was unused after the nurse
administered the medicine. We was shocked after this incident and began to realize that there
is a great need for nurses to acknowledge and prevent such errors to reduce the chance of
cross infection.

Introduction
Errors in administration of medicine are common and can compromise the safety of patient.
This review discusses the causes of drug administration errors in hospital by students and
registered nurses and the practical measure, educators and hospitals can take to improve
nurse’s knowledge and skills in medicine management and reduction in making drug error.
Patient safety and quality care are key aspects of effective health care systems and a principal
goal for health care providers in all health care settings. Care that accommodates the
individual needs of clients increases patient’s safety and, in turn enhances the quality of care.
Multiple causes of MAEs can be grouped under categories such as inadequate knowledge,
failure to follow policy and procedures, communication failures, and individual and systems
issues. Variations from standards of practice, preoccupation and attention slips, interruptions,
distractions, and inadequate staffing are also frequently cited. Nurses perceive medication
errors to be caused by several factors such as heavy workload, distractions, interruptions, and
in experience. Several studies have validated these perceptions, particularly linking
interruptions, distractions, and medication errors. Among all patient-centered standards, the
safety of medication administration is considered a vital indicator of health care quality.
Medication administration errors are estimated to harm 1.5 million people annually and
account for almost 7.6 of 1000 outpatient deaths and 1.2 of 1000 inpatient deaths. The
National Coordinating Council for Medication Error Reporting and Prevention stated that
medication errors can occur while medication is under the control of health care providers,
patients, or consumers. These errors are defined as any avoidable occurrences that could
cause or potentially cause incorrect medication use and/or harm to patients. Medication errors
occur during the prescription, transcription, dispensing, preparation, distribution, and
administration of medication. The complexity of the medication administration process and
the involvement of different health team members increase the potential occurrence of such
errors.

2|
 


Medicineadministrationerror,wrongdoses,missingdosesandwrongmedicationarethemostcomm
onlyreportedmedicineadministrationerrors.Thisnarrativessystematicreviewfoundcaregivermed
icationadministrationratesfrom1.9%to33%ofallmedicinaladministrationerrors.Medicineadmin
istrationerrorsaretypicallythoughtasafailureinoneofthefive“rights”ofmedicationadministration
(rightpatient,medication,time,dose,androute).Thesefiverightsofmedicationgivestandardproces
stosafemedicationadministration.Thefirstreportrelatedtomedicationerrorwaspresentedin1940.

3|
 


Objectives
● Identification of medication administration error in my ward
● Factors associated with medication errors
● Results of medication errors :
● In hospitals, medication errors are the most common causes of morbidity and
preventable death.
● Also, financial penalties may be assessed and legal actions may result. Proper
investigation and documentation can lead to prevention of future errors.

Literature Review
(BRADY, MALONE, & Fleming, 2009) study discuss the causes of medicine administration
error in hospitals by students and registered nurses and the practical measures Hospital can
take to improve nurses knowledge and skills in medicine management and to reduce
medication errors. Medicine error is a significant cause of morbidity and mortality in
hospitalized patients. This create am imperative to reduce medication error and to deliver safe
and ethical care to patients. It is imperative that managers implement strategies to reduce
medication error in creating establishment of reporting mechanisms at National level and
making evaluation system that make nurses accountable of doing and medication errors.
These systematic approaches to medication reconciliation can also reduce medication error
significantly.

(McBride-Henry &Foureur, 2006) stated that medication administration is an

important part of delivery safe patient care despite a desire to deliver high-quality Care

4|
 


address on both a system and personal level. Nurses have holistically taken a beek seat role in
initiatives that have sought to address issues related to medication administration. However,
nurses have developed a significant expertise in medication Administration and have
considerable knowledge of associated system. The quality and safe use of medicine provide
nurses within an opportunity to contribute to National policies on the safe use of medicine.

(Tsegaye, Alem, Tessema, &Alebachew, 2020) conducted a study in Tigray regional state of
Ethiopia which revealed that wrong dose, administering at the wrong time, medication
omission, administering a wrong patient, administering via a wrong route, administering un-
prescribed medication, and administering a wrong drug were the most common types of
Medication administration errors. These errors can be prevented with consistent reporting
systems and by avoiding barriers to report the errors such as fear, heavy workload, time
constraints, and negative employees perceptions of error. The method used to conduct this
study was cross sectional which based on a questionnaire that was used to collect data on
nurses socio-demographic characteristics (salary, an institution where the nurse earned, an
educational award, year of experience, etc), work-related factors (nurse to patient ratio, lack
of written guideline for medication administration, poor communication with other nurses
while facing problems, current working unit, lack of reporting mechanism to medication
errors and duration in specific unit), professional related factors (lack of training and inability
to follow ten rights of medication administration practice) and other factors contributing for
Medication error (Unclear verbal order, illegible physicians handwriting, wrong prescription
and dispensing, look like drugs, nurses prescription in place of physicians, nurse administer
medication prepared by another nurse and physicians frequent alteration of their orders). A
structured observational checklist that contained nine medication administration rights was
used to gather data on a total of 42 nurse. The results concluded in this study discovered that
Wrong time (38.6%) was the most frequently perpetuated Medication administration errors
followed by wrong assessment (27.5%) and wrong evaluation (26.1%).

(Thomas, Donohue-Porter, &Fishbein, 2017) Conducted another study to describe

interruptions, distractions, and cognitive load experienced by registered nurses during
administration of medications and to examine the relationship of interruptions and
distractions on cognitive load.. The method used to conduct this study was hierarchical.
Information collected regarding the participating RNs included their gender, education,
experience, employment status, RN-to-patient ratios, shift worked, and sequence of the shift.
Structural observation sheet, NASA task load index and self-report about distraction
experienced during medication error, was the tools used to evaluate the risk and extent of
medication administration error. The results proposed that there is a significant independent
relationship between a nurse having a distraction, a nurse having an interruption, the number
of interruptions experienced during a medication administration episode, and each cognitive
load measurement (mental demand, temporal demand, physical demand, effort, and

5|
 


frustration). All results yielded P < .05. Nurses with any distraction had a greater perceived
mental, temporal, and physical demand, as well as effort and frustration levels for the
medication administration task, compared with nurses who did not have any distraction.

(Salami et al., 2019) conducted a study in which they found extent medication errors of
medication administration error among nurses of Jordan hospitals. Jordan a developing
country, uses traditional methods in the medication administration process. In this process,
medication prescriptions are handwritten on preprinted forms. In addition, the Jordanian
health care system lacks technologies that help reduce medication errors such as the Pyxis
system, barcode scanning, electronic medical record systems, computer physician order entry,
and automated dispensing machines. Therefore, a lack of technology increases the physical
and intellectual demands on the nurses. For example, nurses have to verify the patient’s
name, drug, dose, time, and route manually.7 In addition, Jordanian nurses experience high
workload that stems from the nurse-patient ratio. In medical/surgical units of public or
teaching hospitals, 1 nurse is often assigned to 13 to 15 patients. In private hospitals, 1 nurse
is often assigned to 8 to 10 patients. In comparison with other countries, this is an
overwhelming workload and can lead to poor patient outcomes. Hence, traditional health care
systems, heavy work, and the lack of technology in the health care system in Jordan
contribute to increasing human errors in respect to medication administration. The focus of
this study is to explore the reason behind these errors and providing safe and effective
strategies to manage and prevent them. The method used for this study was cross sectional
which included questionnaire. The first section collected demographic data from participating
nurses, which included the participant’s age and gender, hospital type, working unit, type of
university graduated from, and type of high school diploma earned. The second section asked
nurses to identify the types of medication errors in respect to the 5 rights of medication
administration: right patient, right time, right dose, right medication, and right route. In
addition, this section asked nurses to estimate the number of MAEs they committed
throughout their career in respect to the route of medication administration: Oral,
subcutaneous, intramuscular, continuous intravenous (IV) infusion, and IV push. The third
section asked nurses to rate the shift that was most highly associated with MAEs. In the
fourth section nurses used a 5-point Likert scale from 1 = never to 5 = always to rank
contributing factors that were associated with their own medication errors.The concluded
results ensured the negligence of night shift nurses about medication error.

Medicationerrorscanbeprevented,arerelatedtothedrugsuseprocessandcancausepatientdam
ageornot.ADE,ontheotherhand,arecharacterizedbythepresenceofdamage,derivingfromanad
versereactionormedicationerror.Medicationerrorsaresystemicandmultipledeterminingfactor
sareinvolved.Amongfactorsrelatedtodrugscontributingtoadministrationerrors,thefollowingst
andout:theadministrationroute,requiredadministrationcomplexity,pharmacologicalcharacte
risticsandthenursingteam’sknowledgeonthedrug.Themedicationadministrationerrorfrequen
6|
 


cyof30.3%foundinthisresearchcansignificantlycontributetoknowledgeaboutthemedicationus
agesafetymethod.Thisstrategyisimportantbecausemedicationerrorsshouldbeaddressedinasy
stemicperspectivethatpermitsevidencingfailuresindifferentsubsystems’processes.Thismakesi
tpossibletoputinpracticeimprovementsanddecreasetheoccurrenceoftheseevents.Itshouldbe
highlightedthoughthat,inordertoachieveeffectiveresultsininterventionplans,itisessentialforpr
escriptionandadministrationprocessestoreceivespecialattention.Thus,theidentificationofdru
gsandotherfactorsassociatedwithadministrationerrorswillalsocontributetotheelaborationofa
ctionplans.Inordertosuperviseandcarryoutmedicationadministrationactivities,nursesneedad
equateknowledgeaboutpharmacodynamics,pharmacokinetics,administrationtechniques,adv
ersedrugreactions,druginteractionsandtherapeuticresponsemonitoringparameters.Thisknow
ledgeisessentialwhenconsideringthevarietyofthetherapeuticarsenalavailableinhospitals,whic
hincreasesdaybydaythroughtheincorporationofnewtherapeuticclasses,newpharmaceuticald
osageformsanddrugsreleasesystems,generatingariskfactorformedicationerror.Periodicalprof
essionalrecyclingisastrategythatcanreducethedivergencebetweennursingprofessionals’know
ledgeandtheiractivitiesinmedicationtherapypractice.Doseerrorswerethesecondmostfrequen
tcategoryinthisresearch.Theseerrorscanberelatedtomistakeinmathematicalcalculationsdurin
gdrugpreparations.Inthisresearch,dosageerrorsareasourceofconcerningas,atmedicalclinicalu
nits,thehospitalizationofgeriatricpatientsisfrequent.Thisagegrouppresentsdecreasedliverand
kidneyfunctions,besidesdecreasedmetabolismandmedicationelimination.Themaindetermini
ngfactorsforthehighincidenceoftimeerrorsareprobablypartoftheadministrationprocess,sucha
sthenursingteam’stimeplanning,whichconcentratesalargenumberofdrugsincertainperiods,ge
nerallyinthemorning.Asaresult,thetimingfordrugsthatrequirepunctualadministration,suchasa
ntimicrobialsandNTID,isnotrespected.Thissituationisgenerallyduetothehighdemandforactivi
tiesandproceduresatthehospitalizationunitduringthemorningshift.Anotherfactorthatcanlead
totimeerrorsistheinadequatefunctioningofthehospitalpharmacy’sdrugsdistributionsystem,le
adingtomedicationdeliveryand,consequently,administrationdelays.Therelationbetweenlacko
fknowledgeandthemedicationadministrationerrorproblemisrelevant.Theadministrationerror
sfoundinthisresearchcanpartiallybeexplainedbythislackofknowledge.Thereisanurgentneedfo
ractionstoimprovenursingstudents’pharmacologyeducationandclinicalnursingprofessionals’r
ecycling.

Purpose
The significant impacts of medication administration error affect patients in terms of
morbidity, mortality and adverse drug events. Medicine errors are the most common errors
that threat health. The purpose of this study is to explore the medication error reporting rates,
error types and their causes among nurses in the emergency department. Medication errors

7|
 


are among the most prevalent health errors, threatening Patient Safety and are regarded as an
index for determining Patient Safety in hospitals.

THE EIGHTCAUSES OF MEDICAL ERRORS

According to the Agency for Healthcare Research and Quality, there are eight common root
causes of medical errors which include:

COMMUNICATION PROBLEMS
Communication breakdowns are the most common causes of medical errors. Whether verbal
or written, these issues can arise in a medical practice or a healthcare system and can occur
between a physician, nurse, healthcare team member, or patient. Poor communication often
results in medical errors.

INADEQUATE INFORMATION FLOW

Information flow is critical in any healthcare setting, especially within different service areas.
Insufficient information flow happens when necessary information does not follow the
patient when they are transferred to another facility or discharged from one component or
organization to another. Inadequate information flow can cause the following problems:
 The lack of crucial information when needed to influence prescribing decisions.
 Lack of appropriate communication of test results.
 Poor coordination of medication orders for transfer of care.
HUMAN PROBLEMS
Human problems occur when standards of care, policies, processes, or procedures are not
followed properly or efficiently. Some examples include poor documentation and labeling of
specimens. Knowledge-based errors also occur when individuals do not have adequate
knowledge to provide the care that is required at the time it is needed.

PATIENT-RELATED ISSUES
These may include inappropriate patient identification, inadequate patient assessment, failure
to obtain consent, and insufficient patient education.

ORGANIZATIONAL TRANSFER OF KNOWLEDGE

These issues can include insufficiencies in training and inconsistent or inadequate education
for those providing care. Transfer of knowledge is critical in most areas specifically where
new employees or temporary help is used.

8|
 


STAFFING PATTERNS AND WORKFLOW

Inadequate staffing alone does not lead to medical errors but can put healthcare workers in
situations where they are more likely to make a mistake.

TECHNICAL FAILURES
Technical failures can include complications or failures with medical devices, implants,
grafts, or pieces of equipment.

INADEQUATE POLICIES
Often, failures in the process of care can be traced to poor documentation and non-existent, or
inadequate procedures

Ways to reduce medication errors:

Confirm that the patient weight is correct, write weight on each order and make sure
that weight based dose does not exceed the adult dose.Ensure that calculations are
correct.Induce dose and volume of medication when appropriate and specify the exact
dosage strengths to be used.Right intravenous fluid orders clearly ensure that
additives are quantified per liter and rates noted per hour.Write out all instructions
rather than using abbreviations and make instruction specificAvoid use of terminal
zero to the right of the decimal point to minimize 10-fold dosing error (i.e use 5ml
rather than 5.0)Use zero to the left of a dose less than 1, to avoid tenfold dosing errors
(for example use 0.1 ml rather than 01 ml).Use computerized order entry system and
standing order sets when available.Avoid use of verbal orders when
possible.Recommends that nurses and pharmacist should always check medications
and calculations.

Recommendations:
1. MINIMIZE CLUTTER

The pharmacy environment is often fast-paced and intense, with high prescription volume,
insufficient staffing, and demanding patients. Keeping pharmacy counters clear and clutter
free can be challenging, but it is an important part of reducing risk for dispensing errors, said
Matthew Grissinger, RPh, director of error reporting programs at the Institute for Safe
Medication Practices (ISMP) in Horsham, Pennsylvania. He advises pharmacies to use a
basket system to keep different patients’ prescriptions and drugs separate, as well as to clear
away the bottles from prescriptions that have been completed. Ideally, he said, pharmacists
should take phone calls in a quiet, distraction-free area.

9|
 


2. VERIFY ORDERS

For prescriptions called in by phone, it’s important to write down and then repeat the order to
verify that it was heard correctly; ISMP recommends spelling drug names during read back.1

E-prescribing comes with its own pitfalls, according to Dixie Leikach, RPh, vice president of
Catonsville and Paradise Professional Pharmacies in Catonsville, Maryland. Her pharmacy
often deals with problems caused by improper use of the technology. For example,
sometimes prescribers can’t find the correct drug strength or dosage form on the e-
prescribing dropdown menu, so they select a similar drug from the list and then write the
intended product in notes in other areas of the prescription, which can be missed during order
entry. “We’ve learned over time that we have to read all the information and clarify if
something really doesn’t make sense,” Leikach said.

3. USE BARCODES

Scanning barcodes plays an important role in checking that the correct drug, dosage form,
and strength has been selected, Grissinger said, ensuring that the most common dispensing
errors are avoided. But he cautions that in the retail environ- ment, this will only work if
orders are entered in the system before selecting the drug bottle; if pharmacists pull the
wrong drug off the shelf and enter its NDC number, barcoding will not catch that error
because the incorrect barcode will appear on the prescription label.

At Boulder Community Health (BCH) in Boulder, Colorado, where Christopher Zielenski,

PharmD, is pharmacy clinical coordinator, the use of barcoding throughout the system, from
dispensing through administration, has resulted in a huge reduction in errors. Since they
began requiring barcode scanning for medications being placed in automatic dispensing
cabinets, the rate of mistakes in filling medications has been reduced to nearly zero, he
reported.

4. BE AWARE OF LOOK-ALIKE SOUND-ALIKE (LASA) DRUGS

ISMP maintains a long list of drugs with similar names that may be confused, which it
recommends printing in bolded tall man (uppercase) letters (egbuPROPion/busPIRone).2 It is
imperative for pharmacists to stay informed about what those drugs are, experts said.
Grissinger advised that every pharmacy choose 5 common LASA pairs and develop strategies
to avoid errors with them, such as separating them. If drugs are separated, he cautioned,
pharmacists and techs need to know where they are located.

Leikach said that LASA lists grow as more drugs become available in generic formulations.
She gave risperidone and ropinirole as an example. “When those were brand names they
weren’t a problem, but once they both went generic and they’re both available in the same
strength... and they’re sitting next to each other on the shelf, all of a sudden you’ve got a huge
potential for pretty severe med errors and adverse drug effects.”

10 |
 


5. HAVE A SECOND PAIR OF EYES CHECK PRESCRIPTIONS

One way to prevent human error is by involving a second human-a pharmacist or technician
(as permitted by state law)-in the dispensing process. “If I’m the one taking the prescription
and entering it, then I’m not pulling the drug and counting it, because I know I have to final
check it,” Leikach said. “Someone else, a tech or another pharmacist, will look at it.... We
check each other.” When she worked in environments where there was no one else there to
check, she would walk away from prescriptions once she’d reached a certain point in the
dispensing process, so that she could come back with “a fresh set of eyes.”

Grissinger cautioned that final checks should always include verification of the original order
entry, whether by keeping the paper prescription with the label and medicine bottle until
completion or by pulling up the scanned prescription on the computer screen.

6. DESIGN EFFECTIVE WARNING SYSTEMS

Various alert strategies can be helpful, but human nature is to overlook the familiar. That’s
why Leikach moves around shelf talkers alerting staff about LASA drugs so they continue to
catch the attention of staff members. She has also requested that the pharmacy software
system change some alerts to hard stops, so that the pharmacist or technician is required stop,
read the alert, and type a response-thus ensuring that they pay attention.

7. INVOLVE THE PATIENT

Patients are their own last line of defense when it comes to medication errors, and investing a
minute or 2 in speaking to them can reap huge dividends in catching medication errors.
Grissinger advises asking the patient when they pick up the prescription: “Open the bag; is
this what you were expecting? Look at the label, look at the name of the drug, look inside the
bottle if it’s a refill to make sure it’s what you got last time.”

Basic counseling can help ensure that patients understand what their prescription is for and
how to take it properly; it sometimes helps catch errors as well. Leikach recalled situations
where she could tell that her explanation did not make sense to the patients. “They said,
‘That’s not why I went to the doctor, that’s not what he told me!’” This enabled her to catch
medication errors made by the prescriber or the dispensing pharmacist, she said.

Speaking to patients is also valuable in obtaining an accurate medication reconciliation,

Zielenski noted, which is why BCH has instituted training in active listening for staff
involved in medication reconciliation.

8. TRUST YOUR GUT

"Pharmacists need to recognize their role to the patient,” Leikach said. “When you receive a
prescription-especially if you get to know your patients-then if something doesn’t make sense

11 |
 


don’t just let it go.” Question the patient and call prescribers to verify, she advised, and if
necessary, dig deeper to obtain clarification on why something was prescribed as it was and
whether it was a mistake. After enough occasions of being thanked by prescribers for
catching their errors, Leikach realized that “you really do need to push when you feel that
something isn’t right,” she said.

9. BE PROACTIVE

“Let’s not keep waiting for things to go wrong and fix them,” Grissinger said. Experienced
pharmacists can sense when things are not going right and should address those concerns, he
said. “Otherwise something’s going to go wrong and the pharmacist is going to get blamed
for that when we saw it coming a mile away.”

ISMP has free self-assessment tools that pharmacists in different practice settings can use to
evaluate how well they are maintaining patient safety. Its Medication Safety Self
Assessment® for Community/Ambulatory. Pharmacy includes over 200 items in 10 elements
important for safe medication use.

Sometimes, Zielenski said, simple changes can have a big impact. For example, BCH started
stocking batteries on the floors after pharmacists realized that barcode medication
administration rates were dropping due to scanner batteries running out. Similarly, BCH
includes dosing and administration instructions with emergency kits.

“Those types of tools can be implemented anywhere,” he noted. “Frontline staff can develop
them; it doesn’t have to come from a manager.”

10. TRACK MEDICATION ERRORS

“I believe in reporting safety events-which are classified as near-misses and errors-even if

they are your own, to allow a big picture to develop so we can identify trends at the system
level and then address those issues and encourage peer-to-peer feedback,” said Zielenski. He
recently published an article describing how BCH developed several interdisciplinary
committees that used medication safety events reported through its voluntary electronic
safety event reporting system to perform continuous quality improvement throughout the
hospital.3 Over the course of 3 years, there was a significant drop in rates of medication errors
and concomitant increase in the rate of near misses, while reporting rates remained the same.

Open discussion of medication errors is most helpful when an institution has a just culture
perspective, Zielenski added. “As soon as it becomes part of a normal conversation, I think
that’s where you really start to gain traction on reducing medication errors,” he said.

12 |
 


Conclusion:
The common cause of errorsmistakable drugs and names of medicines which look alike
patient case is a wider component of quality care nurses administered drugs directly to
patients and they are the last link in the safe medication administration change So always
used proper steps for administering medication by using these steps that desire described in
our study we prevent medication errors. Lack of training, unavailability of guidelines for
medication administration, interruption during medication administration, poor
communication when faced with problems and failure to follow ten rights of medication
administration were factors significantly associated with medication administration errors.
Therefore, stakeholders like the regional health bureau, hospital administrators, and nurse
professionals should collaborate and shared respective responsible to minimize problems
owing to a medication administration error. Medication administration error prevention is
complex but critical to ensure the safety of patients. Providing a continuous training on safe
administration of medications, making a medication administration guideline available for
nurses to apply, creating an enabling environment for nurses to safely administer
medications, and retaining more experienced nurses may be critical steps to improve the
quality and safety of medication administration.

References:
Fekadu T, Teweldemedhin M, Esrael E, Asgedom SW. Prevalence of intravenous medication
administration errors: a cross-sectional study. Integrated pharmacy research & practice.
2017;6:47.

Salami I, Subih M, Darwish R, Al-Jbarat M, Saleh Z, Maharmeh M, Alasad J, Al-Amer R.

Medication administration errors: Perceptions of Jordanian nurses. Journal of nursing care
quality. 2019 Apr 1;34(2):E7-12.

13 |
 


Thomas L, Donohue-Porter P, Fishbein JS. Impact of interruptions, distractions, and

cognitive load on procedure failures and medication administration errors.Journal of Nursing
Care Quality. 2017 Oct 1;32(4):309-17.

Alemu W, Belachew T, Yimam I. Medication administration errors and contributing factors:

A cross sectional study in two public hospitals in Southern Ethiopia.

International journal of Africa nursing sciences. 2017 Jan 1;7:68-74.

Tsegaye D, Alem G, Tessema Z, Alebachew W. Medication administration errors and

associated factors among nurses. International Journal of General Medicine. 2020;13:1621.

Cohen M, Hanson A, Shah N. Top medication errors reported to ISMP in 2019. Webinar
presentation. December 18, 2019. 

https://www.ismp.org/sites/default/files/attachments/2019-12/Top%20Errors
%20handouts.pdf

. Accessed March 6, 2020.

List of Confused Drug Names. Institute for Safe Medication

Practices. https://www.ismp.org/recommendations/confused-drug-names-list.  Published
February 28, 2019.

Hanifin R, Zielenski C. Reducing medication error through a collaborative committee

structure: an effort to implement change in a community-based health
system. QualManag Health Car. 2020;29(1):40-45. doi:
10.1097/QMH.0000000000000240.

Hartnell N, MacKinnon N, Sketris I & Fleming M (2012) Identifying, understanding and

overcoming barriers to medication error reporting in hospitals: a focus group study.
British Medical Journal Quality & Safety 21, 361–368.

Heard GC, Sanderson PM & Thomas RD (2012) Barriers to adverse event and error
reporting in anesthesia. Anesthesia & Analgesia 114, 604–614.

Hughes RG &Blegen MA (2008) Medication administration safety. In Patient Safety and

Quality: An EvidenceBased Handbook for Nurses (Hughes RG ed.). Agency for
Healthcare Research and Quality, Rockville, MD, pp. 397–457.

Hung CC, Lee BO, Tsai SL, Tseng YS & Chang CH (2015) Structure determines
medication errors in nursing units: a mechanistic approach. Western Journal of Nursing
Research 37, 299– 319.

14 |
 


Joolaee S, Hajibabaee F, Peyrovi H, Haghani H &Bahrani N (2011) The relationship

between incidence and report of medication errors and working conditions. International
Nursing Review 58, 37–44.

Kim J, An K, Kim MK & Yoon SH (2007) Nurses’ perception of error reporting and patient
safety culture in Korea. Western Journal of Nursing Research 29, 827–844.

AspdenP,WolcottJ,BootmanL,CronenwettLR. PreventingMedicationErrors.
Washington:NationalAcademies;2007. [GoogleScholar]

WeingartSN,WilsonRM,GibberdRW,HarrisonB.Epidemiologyofmedicalerror. BMJ.
2000;320(7237):774–777. [PMCfreearticle] [PubMed] [GoogleScholar]

PatanwalaAE,SandersAB,ThomasMC,etal.Aprospective,multicenterstudyofpharmacistactiviti
esresultinginmedicationerrorinterceptionintheemergencydepartment. AnnEmergMed.
2012;59(5):369–373. [PubMed] [GoogleScholar]

SchenkelS.Promotingpatientsafetyandpreventingmedicalerrorinemergencydepartments.
AcadEmergMed. 2000;7(11):1204–1222. [PubMed] [GoogleScholar]

PhamJC,StoryJL,HicksRW,etal.Nationalstudyonthefrequency,types,causes,andconsequences
ofvoluntarilyreportedemergencydepartmentmedicationerrors. JEmergMed. 2011;40(5):485–
492. [PubMed] [GoogleScholar]

SenstBL,AchusimLE,GenestRP,etal.Practicalapproachtodeterminingcostsandfrequencyofadv
ersedrugeventsinahealthcarenetwork. AmJHealthSystPharm. 2001;58(12):1126–1132.
[PubMed] [GoogleScholar]

LesarTS,BricelandL,SteinDS.Factorsrelatedtoerrorsinmedicationprescribing. JAMA.
1997;277(4):312–317. [PubMed] [GoogleScholar]

15 |