Medication error is one of the commonest problem faced by medical facilities and it is

considered as a serious issues as such negligence can cause serious harm to the patient. Starting from
the medical personnel prescribing the wrong medication to the pharmacist dispensing the wrong
medication, this problem actually involves multiple department in that specific setting.

There are few factors that can contribute to medication error. Absence of safety culture in the
organisation systems is one of the major factor that can cause this problem. Negligence to a safety
protocol or guideline that has been devised should be avoided to overcome this problem. All the
medication errors must be reported to the respective officers as soon as it is detected. By doing this
medical personnels will be able to make this as a lesson and learn from their mistake. Friends and
colleagues will also be able to learn from others mistakes in this way. This can actually can avoid similar
incidences like this happening in the future. Otherwise, failure to learn from incident and near miss can
also lead to more frequent medication error.

Safe working environment is the key for patient safety. There are few steps that can be taken to avoid
medication error starting from the labelling upto the proper storage of the medication. Ignorance of
such protocol and specific guidelines becomes the key for medication error. Unsafe condition like poor
storage of LASA (Look Alike Sound Alike) medication, cluttered and unlabelled medication must be
avoided to reduce the incidence of medication error. All medications generally should be arranged in an
orderly manner, especially LASA medications, given the chances of choosing and serving the wrong
medication unintentinally is here among them.

There are few ways to overcome medication error problem. TALLMAN lettering may help us in selecting
the correct medication with similar names. For example the label on carBIMazole and carBAMAZepine
bottles can help the pharmacist to identify the correct medication before dispensing it to the patient.
High alert medication like Adrenaline and calcium gluconate are always stored with a red label on it,
indicating a warning like label. This causes the person who deals with the medication to always make an
effort to double check the medication prior to serving it.

Drugs which look alike or sounds alike (LASA) should be kept far from each other so that person who
serving it will not pick the wrong drug. For example, ProGYLUTON and ProGYNOVA should be kept away
from each other to prevent errors from happening. Different contaniners or even different
compartnments in the cupboard can be used to store this drugs separated and away from each other
with a huge label on it. Not only the wrong drug, but serving expired medication is also considered as a
medication error. Therefore, the medications must always be updated and reviewed from time to time
to ensure right

storage and its validity. An expired medication should not be stored and must always be discarded.

Furthermore, the information pertaining to LASA medications can be distributed to all healthcare
providers. By doing this, all healthcare providers will be in the know regarding LASA medications and will
be able to pick up if a medication error has happened or if a near miss has occured. This can be done in a
few manner, the most common and doable being distribution of posters on LASA to every wards and
clinics to ensure everyone is alert on this issue. Besides that, a health talk every now and then regarding
medication safety including LASA medication may also work in favour.

As a nurse, there are numerous roles and responsibilites that can be fulfilled and carried out to ensure
maximum patient safety and in avoiding medication errors. Among which includes education and
training which tops the list. Continuous learning in the form of Continuous Nursing Education or
Continuous Medical Education that is frequently held at the hospital level, department level and unit
level should be attended by all healthcare providers especially nursing staffs. The constant reminder on
these topics can make us more conscious and alert while serving medications, thereby reducing risk of
medication error concurrently. Otherwise, as a nurse, we can play our role by ensuring all high alert
medications are labelled accordingly. For exampe, drugs such as Potassium Chloride should be labelled
with a High Alert Medication label. This will draw attention to anyone handling it, thus reducing the
chances of unintentionally misusing it.

Furthermore, by attending CME’s and CNE’s, we will be in the know of the right calculation method and
preparation of a drug. This will drastically reduce the chances of calculation error hence reducing
chances of medication error simultaneously. Education and training does not necesarily have to be
carried out in a classroom environment. It can be more interactive when done bedside or as part of
orientation when adressing junior staffs or newcomers.

Moreover, implementing proper medication storage system for LASA and TALL MAN lettering for sound
alike medications is also beneficial. For eg : CeLEBREX (anti inflammatory) , CeREBRYX (anti convulsant) ,
CeLEXA (anti depressant) would draw attention to the right medication as the spelling difference is
brought to attention to the user. Other than that, we can also sotre separately LOOK ALIKE medications
by keeping them further from each other. A list of LASA medications provided from the pharmacy can
alert and bring attention to the nurses when they come across them.

Next, ensuring the presence of written instructions from doctors before serving medications can also
further reduce medication error, for example : medications involving ambiguous nomenclature –
Tegretol 1.0mg subcutaneous / Tegretol sublingual 10mg. A written instruction or a proper prescription
slip allows the person serving medication to corss check if in doubt.

Other than that, the 7R’s should also be implemented when administering medications. Among the 7R’s
includes : 1. Right patient

2. Right medication

3. Right dose

4. Right time

5. Right route

6. Right frequency
7. Right documentation

Following these would almost enable a zero error status in ensuring patient safety in terms or
medication related errors. Carrying out Internal Audit would also help keep safe practices in check. The
National Nursing Audit Tool of Ministry of Health, Malaysia can be used. Regular and timely audit keeps
all healthcare staffs on toes. Good safety practices will frequently be revised and reviewed and
practiced.

Besides that, using the “Medication Nurse” vest allows a nurse that is serving medications to alert
onlookers of the nature of his/her job at the moment, resulting in minimal distractions to him/her.
Minimal distractions results in increased alertness and carefulness, thereby minimizing unecessary risks.
Furthermore, as a nurse who is responsible for serving medications, we can always use the 2 identfier of
a patient before administering a medication. This increases chances of ensuring the right medication
being served to the right patient. We can always use patients full name, IC number, Medical Record
Number as their identifiers.

Not only that, but we can also encourage effective communication among nursing staff with patients. An
effective communication with a patient ensures a good rapport and possibly a better memory of the
medical illness suffered by the patient and the reason for their current admission. This way, we can
always be conscious about serving the correct medications and even their doses. Moreover, we can also
encourage the patient to be actively involved in the process if we have a good rapport with our patients.
Lastly, reporting and learning from medication errors can always serve as a good reminder for us as well
as our colleagues to be extra careful when dealing with medications. This will bring alert to all level of
healthcare providers and would result in overall increase of awareness resulting in increased patients
safety. At the end of the day, our patients who are our first priority would always benefit from these
safe practices carried out by us. Despite the hectic work schedule and heavy load of work at times, we
should always remember the seemingly easy steps to be carried out, which is often overlooked is what
causes medication errors that can at times be easily avoided.