Running Head: THE PREVALENCE AND PREVENTION OF MEDICATION ERRORS 1

The Prevalence and Prevention of Wrong Time Medication Errors

Jaime Umpleby

University of South Florida

THE PREVALENCE AND PREVENTION OF MEDICATION ERRORS 2

Ensuring the safety of the patient is a major component of nursing and the patient’s

healing process. Therefore identifying and monitoring the incidence and reasoning for

medication errors is vital in discovering how to decrease errors in regards to patient safety.

Wrong Time Medication Errors

Distractions Leading to Wrong Time Medication Errors

The leading cause of error during medication administration is overwhelmingly due to

interruption or distraction (Hayes, Jackson, Davidson, & Power, 2015). Distractions from the

patient or another healthcare employee can commonly result in a wrong time medication error

(Blignaut, Coetzee, Klopper, & Ellis, 2017).

According to a study completed at a hospital, 43% of medication errors observed out of a

total of 296 errors were due to distractions and resulted in a wrong time medication

administration error (Blignaut et al., 2017). In another study completed over 46 hours in two

different hospitals, 28% of the time during medication administration the patient distracted the

nurse and 30% of the time the distractions were initiated by the nurse (Hayes et al., 2015). Some

nurse-initiated interruptions include diverting attention to events occurring outside of the

patient’s room, communicating with other workers unrelated to the patient’s medication

administration process, and losing focus for unknown reasons (Hayes et al., 2015). It was also

recorded that the most difficult distractions to deal with from the nurse’s perspective were

distractions from the patient, such as patient care needs (Hayes et al., 2015). Nurses stated that

the next most distracting interruption during medication administration was phone calls (Hayes

et al., 2015).
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Consequences of Wrong Time Medication Errors

When linking interruptions with wrong time medication errors, the problem is when

medications are given greater than one hour before or after the ordered time (Lisby, Nielsen, &

Mainz, 2005). Giving a medication at the wrong time can potentially severely harm the patient or

even cause death when looking at the drug’s therapeutic effect and the interactions with other

drugs (Lisby et al., 2005).

Nursing Interventions for Avoiding Wrong Time Medication Errors

To avoid wrong time medication errors, nurses should focus on their time management

skills, such as always putting safe medication administration as a priority and managing

distractions efficiently (Blignaut et al., 2017). Time management skills can be enhanced through

nurse education programs that teach nurses how to manage and prioritize their patient-specific

tasks, while also learning how to handle and minimize distractions throughout the work day

(Hayes et al., 2015).

A Medical Error I am Fearful of Committing

Lack of Knowledge

I am fearful of giving a medication that I should hold and call the provider for, due to

lacking the knowledge or not taking time to learn about the specific medication. As of now, the

amount of medications that exist and how many medications each patient receives is

overwhelming, so I am fearful of giving a medication I should be holding during medication

administration due to this lack of knowledge of medications or lack of time to research each

medication.
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Prevention

To prevent this fear from happening, it is vital that I to take the time I have left in school

to learn about as many medications as I can. I think it is most efficient to learn these medications

in lecture and then apply the knowledge kinesthetically in the clinical setting. Once I graduate

from the nursing program, I know there will still be so many medications I will not know, so I

will need to take the time during each shift to research medications I am unfamiliar with, even if

that means catching up on other tasks later. Once I look up a medication a number of times, I

know it will become more readily absorbed in my brain and I will spend less and less time every

shift having to research medications.

Conclusion

It is shown that an overwhelming majority of medication errors are due to interruptions

and distractions from the patient, nurse, or outside distractors. This can hinder the nurse’s ability

to give a medication at the correct time, causing a degree of consequences to the patient.

Through prioritizing medication administration over other nursing tasks and blocking out other

distractions, this medication error can be prevented.

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References

Blignaut, A. J., Coetzee, S.K., Klopper, H.C., & Ellis, S.M. (2017). Medication administration

errors and related deviations from safe practice: An observational study. Journal of

Clinical Nursing, 26(21-22), 3610-3623. doi:10.1111/jocn.13732

Hayes, C., Jackson, D., Davidson, P.M., & Power, T. (2015). Medication errors in hospitals: A

literature review of disruptions to nursing practice during medication administration.

Journal of Clinical Nursing, 24(21-22), 3063-3076. doi:10.1111/jocn.12944

Lisby, M., Nielsen, L., & Mainz, J. (2005). Errors in the medication process: Frequency, type,

and potential clinical consequences. International Journal for Quality in Health

Care,17(1), 15-22. doi:10.1093/intqhc/mzi015