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MEDICATION ERRORS
Medication Errors
Alaa Alkam
In the United States, approximately 7,000 to 9,000 patients die each year due to
medication errors (Tarik, 2023). Despite advancements in healthcare technology and the
continue to occur causing death, psychological and physical pain, and increased health care
costs.
Medication errors represent significant and enduring challenges within the healthcare
sector, impacting patient safety and healthcare outcomes. In this paper I will discuss common
medication errors, the impact it has on patient health, and current preventative strategies.
Medication errors can occur at any stage in the medication process, from the initial
prescribing to final administration of the drug. Commonly encountered medication errors include
issues such as, miscommunication errors, similar packaging between products (fonts & colors)
and, selection of wrong drug after entering the first few letters.
Miscommunication Errors
giving orders, due to various factors like drugs having similar names, pronunciation errors, or
external distractions. This can be particularly problematic with drugs such as, clobazam and
nimodipine. Studies have shown that approximately 75% of medication errors have been due to
distractions (Tariq, 2023). Physicians have many responsibilities and duties to complete when
they are working and can easily prescribe the wrong medication or order, when they are rounding
Another form of medication error could be due to similar packaging of products. Roughly
30% of medication errors are due to similar packaging and labeling. Below is an image of
infusion solutions that appear to look like the same product due to the same colors, fonts, and
writing. However, these solutions are in fact different. According to the Patient Safety Authority,
“8.7% of wrong-drug and wrong- concentration errors involve mix-ups between these solutions”.
Left: Dextrose 5% and Sodium Chloride 0.45% with Potassium Chloride 20 mEq
Right: Sodium Chloride 0.9% with Potassium Chloride 20 mEq
Similar packaging
Drugs with similar packaging and labeling as seen above can often be misidentified by nurses
Technology Errors
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MEDICATION ERRORS
While technology has decreased the rate of medication errors, there still exists the
potential for selecting the wrong drug, especially when only a few initial letters of the medication
are entered. Some nurses and doctors will only enter the first two or three letters of the
medication and a list of drugs will appear with those same letters. If they do not read the list
properly and select the first drug that is on the list, it can lead to a medicication error. For
example, chlorpropamide and chlorpromazine or dobutamine and dopamine. Nurses can easily
The errors discussed in the paper can be avoided by taking a few seconds to complete
Miscommunication errors can be avoided by reading back or repeating the drug name for
confirmation. One can also spell out the drug name if the drug has a similar phonetically
sounding name to another drug. Mix ups with look a-like drugs can be tricky especially when the
dosage is the only difference. However, a nurse should always double-check the name, dose, and
route of the drug before removing it from the dispenser. Another solution for a hospital is to
place the drugs in completely different cabinets/compartments. They should not be placed side-
by-side or in the same compartment to help reduce errors. As for technology errors, ISMP has
recommended that a minimum of 5 letters should be typed during searches to reduce selection
errors. Nurses should also confirm the name of the drug before removing it.
Medication name, dose, and route should be rechecked when they are in the room with
Impact on Families
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MEDICATION ERRORS
Medication errors do not only impact the patient, but also their families. It could cause
emotional stress, especially if the error resulted in a death. A sudden unexpected death of a
family member can lead to anger, guilt, and anxiety. It can also lead to increased financial burden
due to additional treatments or rehabilitation services. Such incidences can lead to families not
trusting healthcare providers and the healthcare system affecting their decision to seek medical
care. Medical errors can cause a shift in family dynamics. For example, if the patient is the sole
income provider of the family or plays a significant role within the family unit, it can possibly
lead to a shift in the family roles and could lead to long-term instability.
Impact on Students
Like many nursing students, I share similar worries about medication errors. The fear of
professional implications such as losing my nursing license or face legal punishments. To reduce
the risk of giving the wrong medication, I will follow the six rights of medication administration.
Triple-checking the medication, dosage, route, patient, and document everything. I always verify
that the information is accurate and matches the medication that has been prescribed. It’s
important to listen to the patient’s and families concerns because they might have information
that I was not made aware of. It’s also important to check for signs and symptoms of drug
Conclusion
In conclusion, as nurses we can reduce the amount of deaths and damage done by
medication errors by educating ourselves and those around us about the importance of adhering
to the rights of medication administration. It’s essential that we take responsibility for our actions
and care of our patients with the same respect and dignity that we would wish for ourselves –
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MEDICATION ERRORS
seeing them as individuals, not as a room number. The more we are aware about the deaths
associated with medical errors and how common it is becoming; we are more likely to be more
NHS. (n.d.). MHRA Warning – Watch out for look-alikes & sound-alikes. NHS choices.
https://medicines.necsu.nhs.uk/mhra-warning-watch-out-for-look-alikes-sound-alikes/
Pennsylvania Patient Safety Authority. (n.d.). Drug labeling and packaging-looking beyond
http://patientsafety.pa.gov/ADVISORIES/Pages/200709_69b.aspx
Schnoor, J., Rogalski, C., Frontini, R., Engelmann, N., & Heyde, C.-E. (2015). Case report of a
Start the new year off right by preventing these top 10 medication errors and hazards. Institute
new-year-right-preventing-these-top-10-medication-errors-and-hazards
Tariq RA, Vashisht R, Sinha A, et al. Medication Dispensing Errors and Prevention. [Updated
2023 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023