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Medication Errors

Emily T. Canavarros

University of South Florida

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Medication Errors

The medical field, like many other professions, is one with guidelines and principles

established to protect and standardize the practice. However, unlike many other professions, the

lack of adherence to these guidelines can result in disastrous and even fatal consequences. Only

in dissecting the protective layers of nursing practice can we hope to track the deadly

consequences of such errors and safety advances combating future tragedy.

Common Medication Errors

Studies have found that the three most common medication errors included inappropriate

dosage, inappropriate infusion rate and administering medication at a non-scheduled time. These

findings are considerably more surprising when the simple contributing factors are revealed.

“The most common causes of medication errors were using abbreviations (instead of full names

of drugs) in prescriptions and similarities in drug names” (Iran J, 2013, p.2). This finding implies

that the lack of adequate pharmacological information was the strongest contributing factor in

medication errors.

Impact on Patients and Families

The impact on these patients and families can vary anywhere from emotional harm to

prolonged physical impact. All of the three most common errors may have serious and long-term

consequences. Many patients find themselves suffering psychologically from the harm they

endured at the hands of trusted professionals. This emotional harm encompasses: “…depression,

trauma-related anxiety, self-blame, and even an overwhelming sensation of uncertainty and

grief” (Sigall Bell, 2019, p.1). Many battle with the prospect of the organization repeating the

same error. In doing so, these patients are left feeling as if any meaning possibly grasped from

their experienced pain, has been eliminated. Apart from the psychological impact, the prolonged
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physical impact can encompass: “Unintended injury, prolonged hospitalization,

or physical disability” (Thomas L. Rodziewicz, 2022, p. 23). Both physical and emotional

consequences prove to leave quite the impression on the patient.

Avoiding Medication Errors

Avoiding medication errors is often simply a matter of performing conscious and

mindful actions, even in stressful environments. One of the practices combating medication

errors includes the standardization of communication in the profession. The standardization of

communication in nursing helps to eliminate errors resulting from misinterpreted abbreviations

and confusion surrounding similar drug names. The includes tall man lettering, product labeling,

and drug information resources that alert readers to similar drug names. “Additionally, standard

abbreviations and numerical conventions are recommended by The Joint Commission. The ‘do

not use’ list includes general standards for expression of numeric doses. Of note, leading and

trailing decimals (i.e., 0.2mg and 2.0 mg) are discouraged due to the potential for misreading

(i.e., 20 mg)” (Paul MacDowell, 2021, p.1).

The second practice combating medical errors involves optimizing nursing workflow to

minimize error potential. Distractions are often a large contributing factor to errors and

minimizing interruptions while also implementing safety checks, greatly assists in avoiding

mishaps. Medication rooms and medication carts have also been systems purposely implemented

to allow for a private space with limited distractions, so that nurses may fully concentrate on the

task at hand.

Impact on students

Medication errors are not at all uncommon in the less experienced. Errors may be

particularly discouraging to students, as a sense of confidence as a professional is not yet

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developed. This leads to a further feeling of failure and inadequacy if such errors do occur. The

most common medication errors in students include: “Wrong medication calculations, lack of

pharmacological information, unreadable orders in medicine cards, environmental conditions

leading to distraction and having stress in the emergency situation” (Enam Alhagh Charkhat

Gorgich, 2015, p.14). The key differentiating factor between students and established nurses

proved to be the mistakes made whilst experiencing ample stress in emergent situations. Those

with less experience prove to struggle under unfamiliar increased pressure, leaving room for

hasty mistakes.

I fear I will commit a mistake in an emergent situation where I feel unable to ask for

clarity on instructions or appropriate dosages. Both the statistics and my knowledge regarding

my own functioning under emergent stress lead me to believe this. I feel I am extremely unlikely

to commit any errors when I am able to clarify any doubts, as I have no reservations in doing so.

However, when a patient is in a dire situation, I fear there may be a moment of confusion. To

prevent this, I plan to be conscious of my actions and to take a moment to redirect my thoughts

under stress. It is crucial that I remember that any extra moment I spend clarifying dosage or

instructions, is insignificant when compared to the complications following a medication error.

This mindfulness will hopefully redirect and clarify my thoughts.

Conclusion

This paper has altered my perspective on what I believe to be the most important aspects

of nursing care. When envisioning my future career as a nurse, the prevention of medication

errors hardly encompassed my view of the practice. This paper has served as a reminder of the

reality and likelihood of errors in nursing, as in any profession. In acknowledging this, I am now

able to approach the topic with an attitude of prevention and mindfulness. I am further equipped
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with knowledge on the importance of adhering to the seemingly mundane practices that are set to

prevent disastrous and even fatal events. If such an event occurs, I now feel confident in my

ability to recognize the error and proceed accordingly.

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References

Addressing the long-term impact of patient harm. Institute for Healthcare Improvement. (n.d.).

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injury-addressing-the-long-term-impact-of-patient-harm

Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013, May). Types and
causes of medication errors from nurse's viewpoint. Iranian journal of nursing and
midwifery research. Retrieved April 19, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748543/

Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016, August 1).
Investigating the causes of medication errors and strategies to prevention of them from
nurses and nursing student viewpoint. Global journal of health science. Retrieved April 19,
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Medical error reduction and prevention - NCBI bookshelf. (n.d.). Retrieved April 19, 2022, from
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Medication administration errors. Patient Safety Network. (n.d.). Retrieved April 19, 2022, from
https://psnet.ahrq.gov/primer/medication-administration-errors