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Medication Errors: Ways to Prevent the Inevitable. Schaff

Medication Errors: Ways to Prevent the Inevitable

By: Heather Schaff

NUR3225L

18 April, 2022
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Medication Errors: Ways to Prevent the Inevitable. Schaff
One of the biggest nightmares for a nurse is making a medication error. There are many

things that could go wrong when administering a medication not meant for your patient. Nurses

are under public scrutiny now more than ever for medication errors especially with nation wide

coverage of the recent medication error made by Radonda Vaught that ended in a lost life. Even

with all of the steps and safe guards of giving medications, errors are still being made because at

the end of the day nurses and doctors and all other healthcare professionals are human and make

mistakes. That being said, in this paper I am going to go over common medication errors, the

impact they make, and how we can further prevent future medication errors.

Some common medication errors aren't as obvious as one might think and they can occur

very easily. For example, verbal orders from doctor to the nurse are a huge source of error due to

misunderstandings, mispronunciation, mishearing, forgetfulness, and lack of clarification.

Another common error is hand written orders for same reasons as verbal orders. Hand written

doctors orders are well known for being illegible and difficult to decipher. Among other errors

that are preventable are pulling out multiple medications for different patients at one time, not

labeling drawn up medications, and administering a medication that a patient is allergic to. No

matter how the medication error occurs, a patients well being is at risk. While not every error

ends in a life or death situation, it is important that they are reported and explained to the patients

and family members to keep their trust. In a perfect world error wouldn't exist but the world we

live in is full of inevitable error and accidents. Patients and family members heavily rely on

hospital staff for everything regarding health whether its minor or life threatening. I’d say most

people place a lot of trust in hospitals to give them reliable, trustworthy information, and proper

care. In the event of an irreversible error, the heart ache that can be brought to the family is

unimaginable and irreparable. These errors weigh heavily on both the family, the provider, and
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Medication Errors: Ways to Prevent the Inevitable. Schaff
the patient. At the very least, a med error Medication errors are scary for both the nurse and

patient so minimizing the risk for error is a primary focus in health care.

When administering medications there are regulations and steps put in place to minimize

the type of errors described above. When verbal orders kept resulting in errors it became

common for nurses to read back the order to the physician for clarification and instead of saying

fifteen or fifty they would say one five or five zero to avoid dosing conflict. This is now common

practice and very important when accepting orders over the phone or in person. For hand written

orders, nurses are expected to call providers for verbal clarification if they are unsure of what

was written. It is not uncommon to see nurses cluster their care to get things done when they are

busy. Many nurses choose to pull out multiple medications for multiple patients at one time and

that can result in medications getting confused with the wrong patients. It is safer to pull out

medications for one patient at a time and label the medications with your contents, dose, and

your initials. Labeling medications ensures no switch ups are made and that the third check of

medication administration can occur at the bedside. The other two checks happen when the nurse

checks the drug, dose, route, time, and patient at the Pyxis comparing the order on the chart with

the Pyxis screen and the second check when preparing the medication in the med room. Once

entering a patients room with their medications, you want to make sure the it is the correct

patient by having them verbalize their name and date of birth and matching that with their

identification bracelet. Lastly, one of the most important checks is to verify the patient does not

have any allergies by asking them, checking their chart, and looking for an allergy alert band on

their wrist. Verifying that a patient does not have an allergy can prevent anaphylaxis and other

extreme effects of allergic reactions. Prevention is key to limiting the potential for errors to

occur. This is what a group of researchers are trying to accomplish in their journal titled
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Medication Errors: Ways to Prevent the Inevitable. Schaff
“Interventions to Reduce Medication Errors in Adult Medical and Surgical Settings: A

Systematic Review.” In this journal their results state that “Meta-analysis showed that

prescribing errors were reduced by pharmacist-led medication reconciliation, computerised

medication reconciliation, pharmacist partnership, prescriber education, medication

reconciliation by trained mentors and computerized physician order entry (CPOE) as single

interventions (Manias et al., 2020).” They also found that combining these interventions helped

to reduce medication errors. As prevention becomes more of a priority, errors will be

significantly less likely to happen.

While in nursing school, I have heard many nurses say that over the course of their career

that they themselves have made medication errors before. Being a student, those words were

comforting in a way because that means if I were to make a mistake it would be okay. However,

that comfort is drowned out by the fear of knowing that one day I too could make a mistake.

With the recent verdict of Radonda Vaught’s case resulting with a guilty charge, I am heart

broken and horrified for the future of nursing. In a blog dedicated to nursing created by nurses

they quote a statement from the American Nurses Association which states “We are deeply

distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of

mistakes. Health care delivery is highly complex. It is inevitable that mistakes will happen, and

systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical

errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more

effective and just mechanisms to examine errors, establish system improvements and take

corrective action. The non-intentional acts of Individual nurses like RaDonda Vaught should not

be criminalized to ensure patient safety (Chauncey Brusie, ANA, 2022).” I know that now many

nurses will fear reporting a mistake and that is very dangerous for everyone involved. When I
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Medication Errors: Ways to Prevent the Inevitable. Schaff
become a nurse I plan on doing everything in my power to prevent med errors on my behalf. I

take passing medications very seriously and in clinical I do way more than three checks to pass a

medication. Part of medication administration is know what you're giving, the possible side

effect and adverse effects, and the nursing interventions that should follow administration. If I

am unsure about a medication I know that I can always call pharmacy, look it up, or consult the

prescribing physician. I want to practice as safely as possible for the safety and comfort of my

patients.

To conclude, medication errors and errors in general, are a part of healthcare. We as

humans can only do so much in regards to perfection. Making mistakes can happen in a split

second if you are not careful and that is a risk all healthcare professionals have to carry the

weight of. With more precautions and patient safety in mind, we can drastically reduce the

amount of errors that actually occur. I will be sure to follow the five rights of medication

administration and the three checks before passing a medication. Furthermore if I do make a

mistake during my practice, I will report it for the safety of my patients.

By: Chaunie Brusie BSN. (n.d.). Radonda Vaught guilty verdict: What's next? how to show

support? Nurse.org. Retrieved April 18, 2022, from https://nurse.org/articles/nurse-

radonda-vaught-trial/

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult

medical and surgical settings: A systematic review. Therapeutic Advances in Drug

Safety, 11