TRANSFORMING CULTURE TO REDUCE MEDICATION ERRORS 1

Transforming the Culture of Healthcare to Reduce Medication Errors

Theresa L. Joyce

University of South Florida

TRANSFORMING CULTURE TO REDUCE MEDICATION ERRORS 2

Transforming the Culture of Healthcare to Reduce Medication Errors

Humankind exhibits many talents, skills, and gifts that allow an interconnected web of

people to function collectively as a society. Unfortunately, being infallible to mistakes is not one

of these competencies. In every profession, individuals—no matter the level of expertise—are

susceptible to this flaw. For many occupations, error is simply accepted as part of the human

experience; however, employees working in healthcare must constantly stive to push back

against the existence of this imperfection. With the maintenance of life at the tips of their fingers,

accurate and safe medication administration becomes pertinent for the patients being cared for.

Checklist implementation, patient education, and cultural transformation are essential for nurses

to circumvent the possibility of a medication error.

Common Medication Errors

Medication errors can occur in seemingly countless manners, especially in the world of

nursing. These hardworking individuals are usually understaffed, overworked, and burnt out.

Nurses have endless tasks to complete as simply part of the job, not to mention the additional

requests and emotional requirements of each patient being cared for. This leads to the perfect

environment to fester the growth of error. The Institute for Safe Medication Practices has

recognized some of the most frequent mistakes in medication administration in 2019. The most

alarming of those listed were misheard orders, errors resulting from look-alike and sound-alike

drugs, and administering via the incorrect route (“Start the New”, 2020). With such a demanding

occupation, communication may be hindered by nurses and doctors alike as they can be quick to

continue on to the next task, procedure, or patient. Handoff reports, new orders, or important

recommendations can often be heard or perceived incorrectly. In addition, if a nurse is rushing to

complete medication pass on time, he or she may accidentally grab a drug that has a similar
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packaging or name as the one ordered. Moreover, inattention or habit may lead to an unintended

administration of a drug by the wrong route.

Impact on Patients and Families

Every nursing decision made has the potential to affect both the patient and the family.

Many mistakes in medication administration can lead to an impairment in health or even the loss

of life. A misheard recommendation, from nurse to provider for example, carries the possibility

of harming the patient. If a nurse alerts the provider of an electrolyte imbalance caused by a

medication, such as hyperkalemia, but the provider instead hears hypokalemia, he or she may put

in an order for potassium supplements. Perhaps the tired morning shift nurse comes in thirty

minutes later, overlooks the patient’s abnormal lab value in the chart, and administers the

potassium supplements with 0800 medications. Now the patient’s already-elevated potassium

level is exacerbated, and he or she is at risk of sudden cardiac arrest and death. The family would

largely be affected in terms of new loss, financial hardship, and familial instability.

In another scenario on an understaffed floor, a nurse has eight patients that each need a

long list of drugs. Attempting to ensure each patient receives his or her medications on time, the

nurse rushes to the medication room to get warfarin and gabapentin. She instead grabs warfarin

and gemfibrozil, which has a similar packaging and drug name. After administration, the nurse

realizes her mistake. Not only did the patient receive the wrong drug but will also experience an

interaction between gemfibrozil and warfarin: an even higher risk of bleeding. Although the

patient was expecting to be discharged today, now he must stay for prolonged monitoring of

bleeding and International Normalized Ratio (INR); moreover, he will likely be in pain from his

missed drug. His family will additionally be affected when he fails to attend the family reunion

planned later in the day.

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Another simple form of medication error is the inattention to the exact order in the chart.

A nurse may be accustomed to administering a drug orally, so she assumes the same with her

newly transferred patient. What she failed to recognize was that her patient was to have nothing

by mouth (NPO), and the order stated the route was via intravenous bolus (IVB). The drug will

now be much less effective due to the first-pass effect of the liver, and the patient’s symptoms

will not be alleviated. Not only does the patient have to deal with prolonged symptoms, but the

family has to witness their loved one’s discomfort.

Avoiding Medication Errors

Medication errors can always be avoided, most of the time by simple means. The most

basic way to avoid these mistakes is by following checklist implementation or following facility

protocol. For instance, misheard orders can be prevented by using Situation-Background-

Assessment-Recommendation (SBAR) format and the readback method. This allows for

organization of information being communicated and the opportunity for the communicator to

correct the listener if he or she repeats the information incorrectly. To avert the occurrence of

administering look-alike and sound-alike medications, the nurse must triple check the medication

administration record (MAR), reread medication labels, and scan the patient’s barcode. In

addition, it is important to pay attention to the spelling and capitalization of each drug name, as

these are designed to prevent error. Similar steps can be utilized to ensure the correct route of

administration of a drug.

Patient education is not only beneficial to those being cared for, but it may also serve a

role in preventing error. According to a study by BMC Health Services Research, patient and

family education and engagement can help to prevent medical errors (Yoon-Sook, et al., 2020).

Though nurses are with each patient for hours at a time, often multiple times every week, the
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patient is with his or herself at all times. Many are familiar with their medication regimen, side

effects, doses, routes, and beyond. Sometimes when questioning a medication, the best person to

consult is the patient themselves. However, it is important to consider that they only become this

knowledgeable from patient teaching and involvement. Therefore, it is a nurse’s responsibility to

always help the client learn about the medications they are being given because there is always a

chance that the educated patient can warn the next nurse of an unfamiliar or incorrect drug

administration before it occurs.

Though protocol implementation and patient education are great ways to ensure safe

passing of drugs, a complementary approach largely enhances this outcome. Solutions to clinical

incidents have been proven to be more effective when there is a change in culture—with new

attitudes and behaviors regarding the issue (Kelsey, 2017). Transforming hospital culture from

mere task-completing to holistic care is the best way to protect patients. The moment healthcare

workers start treating each individual patient as a human with physiological, emotional, and

psychological needs, each decision faced will be made with care. Rather than treating medication

administration as a chore, nurses should see it as an opportunity to make someone’s life easier,

no matter how small. These professionals should recognize that every action they take affects the

person they are caring for. With this mindset, nurses will be more mindful, attentive, and vigilant

in their work, considerably reducing the possibility of error.

Impact on Students

There are many other forms of medication error in addition to the ones already discussed.

As a future nurse, it is my job to implement ways to prevent these mistakes in my own practice.

Personally, I fear not being able to recognize potential interactions between drugs that a provider

has ordered. For this reason, whenever I come across a new drug or an unfamiliar pairing of
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medications, I will consult a pharmacist or a drug guide to see if the order is safe. In addition, I

worry that as a new nurse I will lack the experienced clinical judgement to know when a drug is

not indicated for administration. If I am ever questioning whether or not to hold a drug, I will be

sure to consult an experienced nurse, the charge nurse, or the provider. It is important to

remember that we are all learning, and the fear of being judged for asking a question does not

outweigh risking a patient’s life.

Conclusion

After thoroughly researching and considering the topic of medication administration

errors, I have augmented my understanding of how nurses can avoid these mistakes. I am able to

recognize that many errors can be skirted by following protocol, education patients, and

providing holistic care. My attitude towards nursing has shifted from task-completing to

providing care to all aspects of patients’ needs to make a difference in their lives. Going into my

career knowing that each patient should be treated not as a job but as human, I will take

accountability in providing care, knowing that it is the nurse’s responsibility to ensure the safety

of every patient.
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References

Kelsey, R. (2017). Patient safety : Investigating and reporting serious clinical incidents.

ProQuest Ebook Central https://ebookcentral.proquest.com

Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards. (2020,

January 16). Retrieved March 5, 2021, from https://www.ismp.org/resources/start-new-

year-right-preventing-these-top-10-medication-errors-and-hazards

Yoon-Sook Kim, Hyuo Sun Kim, Hyun Ah. Kim, Jahae Chun, Mi Jeong Kwak, Moon-Sook

Kim, Jee-In Hwang, & Hyeran Kim. (2020). Can patient and family education prevent

medical errors? A descriptive study. BMC Health Services Research, 20(1), 1–7.

https://doi-org.ezproxy.lib.usf.edu/10.1186/s12913-020-05083-y