1

MEDICATION ERRORS

Medication Errors

Hannah I. Ponder

University of South Florida

2
MEDICATION ERRORS

Medication Errors

Healthcare professionals have a duty to treat and care for their patients in the best way

possible. Patients and their families come to hospitals, clinics, etc. and put their trust within the

employees to do their diligence in caring for their loved ones. When healthcare employees make

a medical error that significantly affects the patient, it can put a great burden on the family,

friends, and especially the patient. Extreme medical errors could even lead to death of the

patient. Medical errors are an unfortunate occurrence where research must be conducted to

determine what went wrong along the line with the patient’s plan of care. One may ask if the

error was preventable and what could have been done differently.

This paper will focus on common medical errors, how medical errors impact the patient

and the family, preventing medical errors, and medical errors from a nursing student perspective.

Common Medication Errors

Misheard drug orders by doctors via verbal or telephone orders, unsafe medication

overrides, and unsafe practices associated with intravenous push medications are three common

medical errors (“Top 10 medication errors and hazards for 2019”, 2020).

Misheard Verbal and Telephone Drug Orders And Recommendations

There may be incidences where a verbal or telephone order from a provider is necessary.

In these incidences, it is not difficult to misinterpret what a provider may be ordering for their

patient. If an order was misinterpreted or misheard it could lead to a nurse administering the

wrong medication to their patient. Utilizing “readback” for clarification of all orders ensures safe

medication administration practices.

3
MEDICATION ERRORS

Unsafe Medication Overrides

Clinical decision support systems (CDDS) are computer-based systems used in the

medical field to hold medical supplies. The purpose of the CDDS is to enhance patient safety

(Justinia et al., 2021). Since these systems have been put in place, medical professionals tend to

rely on the system knowledge and safety when pulling medication. Some medications of a higher

risk to patients may display important information on the screen for the user to acknowledge.

Overriding the message allows the user to pull the needed medication. If the user inappropriately

overrides a medication, it can put the safety of the patient at risk. A study conducted on

physicians showed a high incidence of inappropriately overriding medical safety alerts on the

system (Justinia et al., 2021). Some physicians from the study stated their reasoning was for the

medication benefits outweighing the risk. According to the study, this reasoning was highly

inappropriate with a percentage of 71.9% (Justinia et al., 2021). There are other reasons as to

why a medication was overridden or can be overridden; however, medical professionals should

pay close attention to the displayed medical alerts to optimize patient safety.

Unsafe Intravenous Push Medication Practices

Intravenous medications are administered directly into the bloodstream. Because of this

administration, the medications begin to take effect much faster than other forms and routes of

medications. It’s important to understand how to push various intravenous medications because,

for example, some may cause adverse effects based on the rate at which the medication is

administered. The Gap Analysis Tool (GAT) is used to determine areas of safe practice when it

comes to intravenous push medications. From a study including 233 medical facilities, only 23%

of the participants had taken assessments that demonstrated the competency for proper

intravenous medication preparation and administration (“Top 10 medication errors and hazards
4
MEDICATION ERRORS

for 2019”, 2020). 23% is a significantly low statistic and it shows that more teaching needs to

take place in the workforce to avoid the improper use of intravenous medications that could lead

to serious and devasting medical errors (“Top 10 medication errors and hazards for 2019”, 2020).

Medical Errors Impact on Patients And Families

No matter the medical error, the impact it has on the patient, family, and friends is large

and can be devasting in severe cases. As previously stated, patients and their families put their

trust within the medical facility. When healthcare employees perform errors, the patients and

families may lose the trust that was previously given to the medical facilities while feeling an

array of emotions such as anger, sadness, and betrayal. Not only may people lose their trust with

the healthcare system in the moment of the error, but moving forward it may impact how they

further think about the system. A statewide survey was conducted in Massachusetts to determine

how families feel after a medical error. Over half of the participants reported feeling emotional

about the medical error they experienced as well as avoiding doctors and facilities (Prentice et

al., 2020). 67% of the individuals who completed the survey stated they lost complete trust in the

healthcare system (Prentice et al., 2020).

Preventing Medical Errors

Preventing medical errors is vital when working in the medical field. With verbal and

telephone orders, a nurse needs to perform a read back. The read back ensures the receiving

individual correctly heard the sender of the order. The receiver can also spell out any of the

medications that may have been confused or that sounded like another medication. Once the

nurse has the order, the nurse should obtain a signature from the sender as soon as possible. This

will allow the sender to read the order to ensure the correct order was put in place, followed by

their signature to prove they acknowledged it.

5
MEDICATION ERRORS

Although clinical decision support systems are used as an extra safety system for medical

professionals, they should not be abused. Any medical alert that is displayed should be read

carefully and understood properly by the user before it is overridden. If the user stops to read the

alert and still does not understand the alert or the proper reasoning to override the alert, the user

should ask for assistance. Understanding the medical alert and the correct reason as to why the

alert needs to be overridden are ways in which this type of medical error can be mitigated.

Errors associated with intravenous push medications can be avoided by providing

educational classes for healthcare professionals to attend. The class can be followed by an

assessment to test the employee’s understanding of the material that was learned. Depending on

the score of the individual, they either pass or must remediate. Before an intravenous medication

is given, nurses and providers should be encouraged to review the patient chart. The healthcare

employee should also review the age, ethnicity, past medical history, or any factors that could

have an impact on how the medication is absorbed and what potential side effects should be

looked out for in the patient.

Student Perspective on Medical Errors

As a nursing student, one thing I worry about is making a medical error and potentially

harming one of my patients. After hearing about medical error cases, it makes me want to work

hard to prevent medical errors as best as I can. I am someone who can be easily distracted which

can negatively affect me in the long run. Since I can be easily distracted, I think it would be best

for me to work independently at times where medical errors are likely to occur. If I happen to

make a medical error, I know I should report it immediately to my supervisor or nurse manager

so the proper actions can be taken place towards correcting the error.
6
MEDICATION ERRORS

Conclusion

Medical errors are irreversible mistakes that can have a huge impact on the patient and

the healthcare system. When working in the medical field it is important not to take the job

lightly because lives are at risk. Medical errors can be reduced by properly collaborating as a

team, take time to document the correct information on the chart, use evidence-based practice

techniques, do not be afraid to ask for assistance when a question or concern arrives.
7
MEDICATION ERRORS

References

ISMP: Top 10 medication errors and hazards for 2019. (2020). Reactions Weekly, 1789(1), 6–6.

https://doi.org/10.1007/s40278-020-74356-2

Justinia, T., Qattan, W., Almenhali, A., Khatwa, A., Alharbi, O., & Alharbi, T. (2021).

Medication errors and patient safety: Evaluation of physicians' responses to medication-

related alert overrides in clinical decision support systems. Acta Informatica Medica,

29(4), 248. https://doi.org/10.5455/aim.2021.29.248-252

Prentice, J. C., Bell, S. K., Thomas, E. J., Schneider, E. C., Weingart, S. N., Weissman, J. S., &

Schlesinger, M. J. (2020). Association of open communication and the emotional and

behavioural impact of medical error on patients and families: State-wide cross-sectional

survey. BMJ Quality & Safety, 29(11), 883–894. https://doi.org/10.1136/bmjqs-2019-

010367