Running head: A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT

A Look Into Medication Error and How To Prevent

Liza McGill SN, SMH
University Of South Florida
College Of Nursing

A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT

Abstract
Medication error is a serious problem and is a danger to patient safety. Medication error is part
of the overall medical error. What is medication error? The types of medication error will be
discussed in this paper. What are some ways this type of error can happen? The statistics and
prevalence of this type medication error. Where, when and how does medication error takes
place? Whose responsibility is it to prevent this type of error? The paper will also be discussing
the nursing interventions to help prevent or reduce this type of medication error. What
medication error fear I have, and how I plan to prevent it from happening? Overall, to give clear
and concise information on the issues surrounding the specific type medication errors, nursing
interventions to help reduce or prevent the fear of committing a medication error and the plans to
prevent it from happening.

A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT

A Look into Medication Error and how to Prevent

The issue of medical blunder is nothing new. Medical errors can be defined as the failure of
planned action to be completed as intended or the use of a wrong plan to achieve an aim (The
National Academy of Sciences, 2014). Some common types of medical errors are diagnostic
errors, medication errors and preventative errors, such as a fall just to name a few (The National
Academy of Sciences, 2014). The topic of discussion will be focusing its attention on the
medical error of medication error. Medication use is a multi-step process with the possibility for
mistakes to happen at either the prescribing, dispensing, or the administration stage (Cassidy et
al., 2011). According to the National Coordinating Council for Medication Error Reporting and
Prevention (NCCMERP), a medication error is "any preventable event that may cause or lead to
inappropriate medication use or patient harm, while the medication is in the control of the
healthcare professional, patient or consumer." Medication errors are widely reported for
hospitals, but limited information is available for error committed in clinical and community
based settings (Cassidy et al., 2011). Medication errors can occur during prescribing,
transcribing, dispensing or administration level (Wright, 2013). The objective of this paper is to
look in-depth at the medication error of wrong dose and the interventions to prevent or reduce
such an error, while touching on the medication error that I fear committing and how I plan to
prevent that fear from coming to pass.
About 98,000 people die every year from medical error and a significant number of those
deaths are related to medication administration error (NCCMERP, 2014). A medication
administration error is defined as administration of a medication that does not match the
physician order (Bonkowski et al., 2013). A medication administration error can occur at any
point of wrong medication, wrong route, wrong time, wrong dose and wrong patient. The type

A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT

of medication administration error to be discussed is wrong dose. The error type of wrong dose
of medication can either be too much or too little. Wrong dose is the second most reported
incident of medication error when compare to other reported medication administration error
type (Cassidy et al., 2011). The error of wrong dose can be attributed to many different reasons
such as individual deficiencies, such as calculation skills, limited experience, failure in following
policies, in properly checking drugs, illegible writing etc. (Wright, 2010). It was noted that
wrong dose error was higher in children than it was in adult (Cassidy et al., 2011). Based on
these findings, some nursing interventions were assessed to see how to prevent or reduce this
error.
Nurses serve as the final leg in the medication process and therefore play an important
role in the risk of reduction. The medication error of wrong dose can be reduced by several
nursing interventions. Some nursing interventions are as follows: The most important is
adhering to the five rights of medication process, and ensuring that close attention is paid to the
one for the right dose. Another way to prevent giving wrong medication dosage to patients, is by
double-checking. This can be done several ways. One is to have another colleague
independently check the preparation of the medication to be administered, by performing
calculations for dosing, checking the medication against the prescription order, or checking the
quantity of to be given. Nurses can help reduce administering of wrong dose by adhering to the
policies and procedures of the facility. Another nursing intervention is to pause for a minute just
before administering the medication. Take that time to recheck the order and the medication at
the bedside, to verify that it is the correct dose.
As a nursing student the medication error I fear of committing is not been able to give the
patient the medication at the right time. One way I plan to prevent this by figuring out which of

A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT

patient is more acute and tend to them first. Another way to try and prevent my fear from
coming to pass, is by doing a focused assessment in the morning based on the patient illness,
then later on I can go back and do another assessment for trivial things. Another way is to go
into each room and introduce myself and check to see if they have any pain, nausea or any other
needs that need immediate attention. Finally, I would look at their medication list and write the
times down for their medication to be given and keep a track of what needs to be given and at
what time.
In comparison to other medical errors, medication errors occur more frequently.
Likewise, when it comes to medication administration, wrong dose error was the highest when
compared to other administration errors. Although certain interventions where discussed for
wrong dose medication error, I talked about my medication error fear and the plans I have to
prevent it, it was still challenging to find information on each specific type of medication error.
Medication error is a medical error that has continue to cost healthcare billions of dollars (Seibert
et al.,). Medication error can result in harm or no harm. Since the implementation of Bar code
Medication Assistance, it has helped in lessening the number of mediation error causing a
significance drop in wrong dose (Seibert et al.,). A medication administration error is any
discrepancies between the prescriber order and dose to be administered. In preventing
medication error all professions must work together as a team when it comes to the medication
processes, as it is a multifaceted process.

A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT

References
Bonkowski, J., Carnes, C., Melucci, J., Mirtallo, J., Prier, B., Reichert, E., & ... Weber, R. (2013).
Effect of Barcode-assisted Medication Administration on Emergency Department
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Cassidy, N., Duggan, E., Williams, D. P., & Tracey, J. A. (2011). The epidemiology and type of
medication errors reported to the National Poisons Information Centre of Ireland.
Clinical Toxicology (15563650), 49(6), 485-491. doi:10.3109/15563650.2011.587193
Institute of Medicine- To Err is Human: Building a safer Heath System. The National Academy
of Sciences. Retrieved November 11, 2014, from www.iom.edu/Reports/1999/To-Err-isHuman-Building-A-Safer-Health...
NCCMERP- About Mediation Errors. Retrieved November 11, 2014, from
http://www.nccmerp.org/about-medication-errors?USP_Print=true
Wright, K. (2010). Do calculation errors by nurses cause medication errors in clinical practice? A
literature review. Nurse Education Today, 3085-97. doi:10.1016/j.nedt.2009.06.009
Wright, K. (2013). The role of nurses in medicine administration errors. Nursing Standard,
27(44), 35-40
Seibert, H. H., Maddox, R. R., Flynn, E. A., & Williams, C. K. (2014). Effect of barcode
technology with electronic medication administration record on medication accuracy
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doi:10.2146/ajhp130332

A LOOK INTO MEDICATION ERROR AND HOW TO PREVENT