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Medication Errors

Jadyn M. Koestering

University of South Florida

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Medication Errors

A medication error is any harmful event involving a medication that a healthcare

professional could have avoided. Disturbingly, medication errors are much more common than

most would believe and are a prevalent problem with patient care today. Every year in the US,

nearly 10,000 people die because of a medication error, and over 10x that number experience a

harmful experience related to a medication error each year (FDA, 2019). Healthcare

professionals are the people we trust to help cure our diseases, treat our infections, and ultimately

improve our lives, but we do not expect them to be the people who cause us harm. Improving the

quality of care provided by our healthcare professionals is crucial and this is only possible if we

recognize common medication errors, understand the impact they have on patients, learn to avoid

them, and teach new healthcare professionals how to prevent them.

Common Medication Errors

Recognizing common medication errors is a significant step in decreasing the number of

medication errors made by nurses. Common nursing medication errors include administering the

incorrect medication, the incorrect medication dosage being administered, and the incorrect

patient receiving medication. The incorrect medication being administered can cause many

adverse reactions that can be fatal. For example, a patient with a severe allergic reaction to

penicillin should not be given penicillin. If this patient is given this medication it can cause

extreme harm or death. This error could occur if a nurse is not completely focused on the task at

hand. If a nurse is distracted, they could forget to complete all of the medication rights and to

check for allergies. It is also common for nurses in the clinical setting to pull all of their

medication out of the pixus at once. This makes it music easier to mix up medications and could

increase the chance of giving a patient the wrong medication. The incorrect dosage of a
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medication being administered to a patient can also cause drastic harm. For example, if a patient

with diabetes is given too much insulin, the patient can become hypoglycemic. This can be very

dangerous for patients. This error could occur if a nurse is not properly educated about an insulin

sliding scale or the insulin mixing protocol. Another common medication error would be

administering a medication to the wrong patient. This mistake can put patients at extreme risk.

For example, if a nurse gives metoprolol to a hypotensive patient it can cause their blood

pressure to decrease even more. This error can occur if a nurse is not verifying the patient's

identity by asking them their name and date of birth. Asking the patient these questions can

decrease the frequency of this medication error from occurring. Ultimately, medication errors

can and should be avoided using the rights of medication administration.

Impact on Patients and Families

These medication errors can have drastic impacts on the patient and their family

members. The errors can cause a patient's state to decline and this can be discouraging and

frustrating. The errors can also be ultimately fatal. Hearing that your loved one is suffering or

dying because of a medication error made by a healthcare professional can cause extreme grief

and anger and can lead the patient or family member to not trust healthcare workers altogether.

This can lead them to not want to reach out for help from the health care system when they need

it, and this can lead to more tragic outcomes. Recognizing common medication errors and taking

the necessary steps to avoid them is important and necessary. Nurses need to be properly

educated and have experience with proper protocol to prevent errors.

Avoiding Medication Errors

Medication errors can be avoided by always completing all of the medication rights

before administering any medication to a patient and by being properly educated with strong
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clinical experience (Gunes, 2020). Going through all of the medication rights will prevent the

nurse from mixing up patients, medication, dosages, frequencies, routes, times, and more. The

purpose of this process is to prevent almost all medication errors, but sadly it is not always

carried out. Nurses can get lazy or forget to go through these steps. It can also be normalized to

not complete these medication rights once out of school. This normalization needs to stop and it

needs to be normalized to always complete the medication administration rights. It is also very

important for nurses to be educated on how to complete safe medication administration and to

have practice before doing it independently. This is why it is so important for students to take

clinical time and preceptorship very seriously. This is where they can learn safety protocols and

gain experience on how to practice safely as a nurse (Tariq et al., 2023).

Impact on Students

Healthcare professionals should always complete the necessary steps to help prevent

medication errors, but mistakes happen even when a healthcare professional practices as safely

as possible. The medication error that I fear the most is IV pushing a medication incorrectly. For

example, pushing too much of a medication or pushing a medication too quickly can be very

harmful. IV push medications are dangerous because they are administered into the bloodstream

extremely quickly, so these need to be done very carefully. Pushing an IV medication too

quickly or in the wrong amount can cause fatal adverse reactions. It is also very high risk

because these medications can not be stopped. Once a medication is directly pushed into the

bloodstream, there are few interventions that can reverse these actions. It is crucial for healthcare

professionals to go through all of their safety checks and practice safely when administering IV

push medications.
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Conclusion

Completing this paper has allowed me to reflect on how intensely important safe

medication administration is. All medication errors can be avoided by proper and precise nursing

practices. I believe that this is one of the most important roles of a nurse. Nurses are commonly

the last line of defense in medication administration. They are the ones performing the final

medication check before administering it to the patient. They are the last thing between the

patient and the medication. In clinical practice, it is common for me to notice that nurses do not

always perform all of the necessary medication checks. This paper has made it obvious to me

that this normalization needs to change. Proper medication administration needs to be

normalized instead of the lack of it. Nurses need to be properly educated and need to always

perform the proper medication safety checks.

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References

FDA. (2019). Working to reduce medication errors. U.S. Food and Drug Administration.

https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-

medication-errors#:~:text=A%20medication%20error%20is%20defined,Medication

%20Error%20Reporting%20and%20Prevention

Tariq, R., Vashisht, R., Sinha, A., et al. (2023). Medication Dispensing Errors And Prevention.

In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK519065/

Gunes. (2020). Medication Errors Made by Nursing Students in Turkey. International Journal

of Caring Sciences., 13(2), 1183–1192.

http://www.internationaljournalofcaringsciences.org/docs/31.%20kocyigit.pdf