CHARACTERISTICS OF MEDICATION

ERRORS MADE BY STUDENTS DURING THE

ADMINISTRATION PHASE:
A DESCRIPTIVE STUDY
ZANE ROBINSON WOLF, PHD, RN, FAAN,* RODNEY HICKS, MPA, MSN, ARNP,y AND
JOANNE FARLEY SEREMBUS, EDD, RN, CCRNz

Faculty concentrate on teaching nursing students about safe medication administration

practices and on challenging them to develop skills for calculating drug dose and intravenous
flow rate problems. In spite of these efforts, students make medication errors and little is
known about the attributes of these errors. Therefore, this descriptive, retrospective,
secondary analysis study examined the characteristics of medication errors made by nursing
students during the administration phase of the medication use process as reported to the
MEDMARX, a database operated by the United States Pharmacopeia through the Patient
Safety Program. Fewer than 3% of 1,305 student-made medication errors occurring in the
administration process resulted in patient harm. Most were omission errors, followed by
errors of giving the wrong dose (amount) of a drug. The most prevalent cause of the errors
was students’ performance deficits, whereas inexperience and distractions were leading
contributing factors. The antimicrobial therapeutic class of drugs and the 10 subcategories
within this class were the most commonly reported medications involved. Insulin was the
highest-frequency single medication reported. Overall, this study shows that students’
administration errors may be more frequent than suspected. Faculty might consider
curriculum revisions that incorporate medication use safety throughout each course in
nursing major courses. J Prof Nurs 22:39 – 51, 2006. A 2006 Elsevier Inc. All rights reserved.

T HE ADMINISTRATION OF medications is a vital

and valued aspect of nursing practice (Cheek,
1997). Early in professional nursing education pro-
grams, nursing students learn about medication admin-
istration from nursing and pharmacology courses and
textbooks. They solve medication dose and intravenous
flow rate calculation problems in various courses until
their skills are deemed acceptable by programmatic
standards. Then, students perform these tasks in
supervised clinical experiences.
Faculty may test students’ calculation abilities se-
quentially during a course or these skills may be tested
across a basic curriculum. Routine testing of dose
calculation performance is recommended to document
*Dean and Professor, La Salle University School of Nursing,
Philadelphia, PA.
yResearch Coordinator, United States Pharmacopeia, Rockville, MD.
zAssociate Professor, La Salle University School of Nursing, Phila-
delphia, PA.
Address correspondence and reprint requests to Dr. Wolf: PhD, RN,
FAAN, Dean and Professor, La Salle University School of Nursing, 1900
West Olney Ave., Philadelphia, PA 19141.
8755-7223/$ - see front matter
progress and to reveal areas for improvement (Ashby,
1997). In addition to dose calculation practice, many
factors contribute to knowledge and skill acquisition in
medication administration. Typically, students’ abilities
grow during their program of studies. Clinical experi-
ence is essential in the development of sound clinical
reasoning abilities (Byrnes & West, 2000). However,
practice with drug calculations in the clinical area may
be limited owing to agency policies that do not permit
students to administer medications (Adams & Duffield,
1991; Bindler & Bayne, 1984; Dexter & Applegate,
1980; McColgan, 1984) although opportunities for
practice are numerous. Furthermore, unit dose packag-
ing has also been implicated as a factor that decreases
opportunities for the practice needed to acquire com-
putational acumen (Bindler & Bayne, 1984; Dexter &
Applegate, 1980; McColgan, 1984; Ptasynzki & Silver,
1981; Schwartz & Jackson, 1980). Because of students’
limited clinical experience, they may be at risk of
committing mistakes (i.e., medication errors) associated
with medication administration.
A logical assumption would be that by administer-
ing medications, students and faculty intend to

Journal of Professional Nursing, Vol 22, No 1 (January – February), 2006: pp 39 –51 39

A 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2005.12.008
40
improve patients’ situations while at the same time
avoiding harming them. Nursing faculty emphasize the
seriousness of this charge and discuss safety strategies
in classroom presentations and during clinical super-
vision. For faculty and students alike, the standard of
perfection imposed on them regarding mistakes
involving patients (McClure, 1991; Smith & Forster,
2000) has been internalized. When nursing students
or other health care providers make medication and
other errors, they may be panicked, horrified, and
apprehensive (Arndt, 1994; Hilfiker, 1984, 1985;
Wolf, 1994; Wolf, Serembus, Smetzer, Cohen, &
Cohen, 2000).
Patients and families cope with the consequences of
medication errors made by health care providers, some
of whom are nursing students (Classen, Restonik,
Evans, Lloyd, & Burke, 1997; Gladstone, 1995), as
may the faculty who supervise them. The suffering that
follows medication errors affects patients and, at the
same time, the health care providers involved in the
error (Serembus, Wolf, & Youngblood, 2001; Wolf,
1994), including students. For example, when a nurse
described in great detail a medication error she made as
a nursing student, she noted how inadequate and
humiliated she felt because bgood nurses don’t make
mistakes.Q Her faculty shared an account of the error in
class so that other students would know that such
mistakes happen. This public sharing of the error was
done regardless of the student’s vulnerability and
embarrassment (Wolf, 1994).
Additional research is needed to identify the most
effective teaching strategies that support the develop-
ment and enhancement of clinical reasoning abilities
and skills in nursing students and inexperienced
registered nurses, as these abilities apply to medication
administration and other nursing responsibilities. These
methods might assist students and practicing nurses in
enhancing their clinical practice knowledge and skills
(Byrnes & West, 2000). Currently, limited research is
available on the attributes of student-made medication
errors and the effective teaching strategies that help
students avoid them.
Many reasons exist why limited information regard-
ing medication errors and nursing students is available.
Organizations that collect information about medication
errors in general or student-made errors in particular
may not be willing to share such reports publicly for
fear of legal liability. In addition, few reports exist
within a single organization (Kohn, Corrigan, &
Donaldson, 1999). Errors may also be rectified with
no other action than reporting.
Large national databases afford an opportunity to
explore phenomena that might occur in low frequency
in a single health care setting. One such database is the
MEDMARX, which is operated by the United States
Pharmacopeia [USP] (2002, 2005) through its Patient
Safety Program. The MEDMARX is a national, voluntary,
internet-accessible medication error database that has
been used by more than 700 hospitals and health systems
WOLF ET AL
since September 1998. Employees of participating
facilities enter, review, and then release the data to a
central data repository that is then available for all
subscribers to search. The MEDMARX database includes
the largest known database on medication errors made
by nursing students.
More information is needed about student-made
errors. Therefore, the purpose of this study was to
describe the characteristics of medication errors made
by nursing students during the administration phase of
the medication use process as reported to the MED-
MARX. In this study, characteristics are defined as the
attributes of a medication error event recorded on
error reports. A medication error is defined as b[a]ny
preventable event that may cause or lead to inappro-
priate medication use or patient harm while the
medication is in the control of the health care
professional, patient, or consumer. Such events may
be related to professional practice, health care prod-
ucts, procedures, and systems, including prescribing;
order communication; product labeling, packaging,
and nomenclature; compounding; dispensing; distribu-
tion; administration; education; monitoring; and useQ
(National Coordinating Council [NCC] for Medication
Error Reporting and Prevention [MERP], 2005). We
assumed that most of the errors were those made by
nursing students because they were reported as admin-
istration errors. We also assumed that the data submit-
ted by participating facilities were accurate.
Review of the Literature
Various studies have addressed nursing students’ per-
formance in calculating medication doses. It has been
well documented that many college students arrive on
campus prepared to meet the challenges of higher
education with mathematics skills at or below the 7th-
grade level (Hutton, 1998). For example, Bindler and
Bayne (1984) asserted that basic mathematics proficien-
cy is a prerequisite to nursing functions, including
medication calculation and intravenous regulation.
They created a mathematics proficiency test for nursing
students that included words and symbols; addition,
subtraction, multiplication, and division of whole
numbers; basic functions with decimals; computation
of fractions; knowledge of ratios and proportions; and
simple story problems requiring use of basic functions.
The investigators established a passing grade of 80% for
a basic skill level. They created a medication calculation
test that added confirmation of proficiency in the three
measurement systems used by nurses (metric, house-
hold, and apothecary), with a passing grade of 70%. The
latter test was administered to students after successful
completion of the mathematics proficiency test. Bindler
and Bayne concluded that large numbers of nursing
students lacked skills in areas of mathematics basic to
the registered nurse role. Such skill deficiencies might
be corrected during basic programs; however, if they are
not addressed, they can be associated with medication
STUDENT–MADE DRUG ADMINISTRATION ERRORS
errors made by practicing nurses. Worrell and Hodson
(1989) conducted a survey of 223 nursing programs to
identify nursing student deficiencies in basic mathe-
matical concepts for drug dose calculation. Associate
degree, baccalaureate, and diploma programs reported
that many students were deficient in basic mathematical
concepts, and the programs did not differ significantly
regarding student deficiencies. Blais and Bath (1992)
analyzed the types of dose calculation errors by
baccalaureate nursing students following fundamentals
of nursing and pharmacology courses. The responses to
a 20-item examination revealed three types of errors:
conceptual errors (setup and form), mathematical errors
(addition/subtraction, multiplication/division, decimals,
and fractions), and measurement errors (metric and
apothecary). Conceptual errors predominated. The
authors suggested that faculty emphasize problem-
solving strategies to help students conceptualize the
dose calculation problem and evaluate students’ basic
mathematical ability. They recommended monitoring
students’ calculation of drug doses throughout the
nursing major and emphasized the need to be consistent
in the use of formulas for calculating doses throughout
the program. In contrast, Segatore, Edge, and Miller
(1993) investigated whether preclinical baccalaureate
nursing students could calculate medication doses
correctly at an 85% level or higher and subsequently
described the nature and magnitude of errors. Students
made conceptual errors or errors of form (failure to
provide the correct form of the medication) or setup
(failure to provide the correct formula). These were
more frequently made than were mathematical errors
(incorrect addition, subtraction, multiplication, divi-
sion, use of decimals and fractions). They recommended
that students focus on thinking through problems and
that faculty emphasize the importance of computational
accuracy. Segatore et al. affirmed that safe medication
administration incorporated an ethical responsibility on
the part of faculty; students should not be permitted to
administer medications until weaknesses are corrected.
Also, they suggested that students be tested many times
across courses with clinical specialty components and
that meaningful consequences be attached to failure.
Likewise, the results of the comparative descriptive
design study of Pozehl (1996) pointed to the lower
performance in an algebra skills test, as well as more
mathematics anxiety, of nursing students as compared
with non-nursing students. The investigator recommen-
ded early evaluation of mathematical calculation skills
as well as selective admission requirements, such as
ACT and SAT scores, for assessing mathematics com-
petence. Next, Polifroni, McNulty, and Allchin (2003)
surveyed a randomly selected proportional sample of
nursing schools in the United States and acute care
institutions with a Magnet Program Recognition Award
status on validation of mathematical competence for
medication administration. The questionnaire elicited
practices, policies, and procedures related to validation
of mathematics competency for drug administration.
41
They concluded that nursing students and new gradu-
ates have difficulty with basic mathematics and recom-
mended numerous practice opportunities to develop
and maintain skills and a required 100% passing score
to document competency in conceptual processing and
computational ability.
Craig and Sellers (1995) conducted a quasi-experi-
mental study on the medication dose calculation
abilities of nursing students by comparing dimensional
analysis, ba method used whenever two quantities are
directly proportional to each other and one quantity
must be converted to the other using a conversion factor
or conversion relationshipQ (p. 15), with the traditional
problem-solving method of ratio–proportion or desired
dose–dose on hand methods. Students in the dimen-
sional analysis group demonstrated greater improve-
ment in the medication calculation test than did those
taught by traditional problem-solving methods.
Flynn and Moore (1990) examined the relationship
between nursing students’ mathematics performance and
mathematics attitude, state anxiety (transient appre-
hensiveness), SAT mathematics score, grade point aver-
age, number of high school mathematics courses, age, and
sex. Core course grade point average and mathematics
attitude were significant predictors (R 2 = 26%) of
mathematics performance. The investigators recommen-
ded using these predictors early in the curriculum to
identify students who may have difficulty with mathemat-
ical calculations. They suggested faculty assistance, tutor-
ing, self-study workbooks, and computerized instructions
as resources for students.
In contrast, Zellner, Boerst, and Semling (2003)
compared students’ performance on a National League
for Nursing (NLN) computerized adaptive pharmacol-
ogy test by two delivery methods, integrated pharma-
Table 1. Error Category Index4 of Administration Errors by
Students From January 1, 1999, to December 31, 2003
(N = 1,305)
Category Definition n %
B Error did not reach patient 50 3.8314
921
C Error reached patient; 70.5747
no harm
D Error required extra patient 304 23.2950
monitoring
Ey Error required extra 28 2.1455
treatment
or intervention;
temporary harm
Fy Error resulted in initial or 1 0.0007
prolonged hospitalization
and temporary harm
Hy Error resulted in near-death 1 0.0007
event
1,305
Total 100.0000z
4National Coordinating Council for Medication Error Reporting and
Prevention Index.
yErrors resulting in harm.
zRounded off.
42 WOLF ET AL

Table 2. Types of Administration Errors Made by Students ing dose calculations. Papastrat and Wallace (2003)
(N = 1,208) described a problem-based learning approach used in
classroom and clinical settings to help students under-
Type n %
stand why medication errors occur and to assist them in
Omission error 248 19.00 creating prevention strategies. They applied theories of
Improper dose/quantity 224 17.16
Wrong time 221 16.93
Extra dose 184 14.09 Table 3. Causes of Students’ Medication Errors (N = 1,135)
Wrong patient 120 9.19
Unauthorized drug 110 8.42 Cause n %
Wrong route 47 3.60 579 51.01
Performance (human) deficit
Wrong administration technique 44 3.37 362 31.89
Procedure/protocol
Wrong drug preparation 40 3.06
not followed
Wrong dose form 5 0.38 301 26.52
Knowledge deficit
Prescribing error 1 0.07 192 16.92
Communication
Not classified by type 61 4.67 90 7.93
System safeguard(s)
Total 1,305 100.004 88 7.75
Documentation
Records in which types of 1,208 92.56 46 4.05
Monitoring inadequate/lacking
errors were reported Dose form confusion 33 2.91
Total no. of types of 1,244 29 2.56
Calculation error
errors reported Written order 24 2.11
4Rounded off. Incorrect medication activation 21 1.85
Drug distribution system 19 1.67
cology content throughout a 4-year curriculum and a Handwriting illegible/unclear 18 1.59
Dispensing device involved 16 1.41
separate pharmacology course during the sophomore
Transcription inaccurate/omitted 16 1.41
year. The NLN computerized adaptive pharmacology
Packaging/container design 14 1.23
examination (normed test) tested calculations, princi- 10 0.88
Abbreviations
ples of medication administration, and effects of Brand names look alike 10 0.88
medication, including therapeutic and side effects. Brand names sound alike 10 0.88
Results of the retrospective study indicated that the Pump, improper use 9 0.79
curricular conversion to teaching pharmacology in a Brand/generic names look alike 7 0.62
separate course showed no increase in scores as Computer entry 7 0.62
compared with the integrated pharmacology course. Generic names look alike 7 0.62
The integrated curriculum group scored better than the Information management system 7 0.62
pharmacology course group. This was attributed to Preprinted medication order form 7 0.62
Brand/generic names sound alike 6 0.53
applications achieved from experiences during clinical
Diluent wrong 6 0.53
placements across the program. The researchers pointed
Equipment design 6 0.53
out the few studies comparing separate pharmacology 5 0.44
Labeling (your facility’s)
courses versus integrated pharmacology content and Generic names sound alike 4 0.35
questioned whether nursing students and newly Label (manufacturer’s) design 4 0.35
employed nurses possessed adequate knowledge of Prefix/suffix misinterpreted 4 0.35
basic pharmacology. They emphasized the importance Computer software 3 0.26
of pharmacology in nursing practice and the necessity Label (your facility’s) design 3 0.26
of reinforcing the content throughout the nursing Measuring device 3 0.26
curriculum. Reference material 3 0.26
Many nursing faculty have investigated strategies to Similar packaging/labeling 3 0.26
Verbal order 3 0.26
increase the dose calculation skills of nursing students.
Contraindicated, drug allergy 2 0.18
For example, drill-and-practice problems delivered
Contraindicated, drug/drug 2 0.18
through computer-assisted instruction have been related 2 0.18
Decimal point
to students’ success on medication calculation compe- Pump, failure/malfunction 2 0.18
tency tests (Adams & Duffield, 1991; Reynolds & Storage proximity 2 0.18
Pontius, 1986; Thiele, 1986), as well as their positive Contraindicated in disease 1 0.09
attitudes (Hamby, 1986) and decreased anxiety regard- Contraindicated, drug/food 1 0.09
ing dose calculation (Timpke & Janney, 1981). Algo- Fax/scanner involved 1 0.09
rithms for calculating intravenous drip rates (Connor & Leading zero missing 1 0.09
Tillman, 1993) and calculator use for arithmetic and Nonmetric units used 1 0.09
conceptual skills development (Murphy & Graveley, No cause identified 170
Records in which types of causes 1,135 86.97
1990; Shockley, McGurn, Gunning, Graveley, & Till-
were reported
otson, 1989; Tarnow & Werst, 2000) have also been
Total no. of causes reported 1,990
used to improve nursing students’ performance regard-
STUDENT–MADE DRUG ADMINISTRATION ERRORS 43

error to classify preventable adverse drug events by first- Table 5. Actions Taken After Errors Were Made (N = 1,305)
semester baccalaureate students and faculty during a 10-
week clinical experience. Problem-based learning scenar- Actions Taken n %
ios were posed and questions and statements guided Informed staff who made the initial error 381 55.30
discussions. The situations encouraged the development Education/training provided 301 43.69
of critical thinking regarding medication administration Informed staff who was also involved in error 178 25.83
and errors. Finally, Allen and Pappas (1999) described a Communication process enhanced 115 16.69
4-year program to assist students in being successful with None 55 7.98
mathematical competency. They considered opportuni- Informed involved patient’s physician 23 3.34
Informed patient/caregiver of medication error 21 3.05
ties to give medications and to earn a high clinical grade
Policy/procedure changed 8 1.16
to be incentives for improving mathematical skills. 7
Staffing practice/policy modified 1.02
Recommendations included a multifaceted approach Environment modified 4 0.58
such as student accountability, faculty sensibility to the Policy/procedure instituted 2 0.29
source of the problem, and creative interventions. They Records in which actions were reported 689 52.79
advised that computer-assisted mathematics programs Total no. of actions reported 1,095
should be given to students as a supplemental strategy. In
addition to mechanisms for early recognition of mathe-
matical calculation difficulty and reinforcement during
each semester, Allen and Pappas suggested that dose reported in the USP MEDMARX program. In this
calculation problems be worded in clinical terms that secondary analysis study, characteristics were elicited
linked calculations with patient safety. through the pick fields of the MEDMARX Medication
Much of the literature examined dose calculation Error Information Report as selected by employees of
issues for nursing students, but limited literature was facilities subscribing to the MEDMARX program. The
found on the characteristics of nursing students’ errors. intent was to gain more knowledge about student-made
Anecdotal reports have been shared among nursing medication errors.
faculty over time as part of their oral tradition. The
dearth of literature justifies this study. Sample and Setting
The convenience sample of student-made medication
Methodology errors (N = 1,305) was obtained from reports voluntarily
submitted to the USP MEDMARX database of medication
Design
errors. The MEDMARX is an anonymous internet-
This descriptive and retrospective design study aimed to accessible program used by subscribing hospitals and
identify characteristics of medication errors made by health care systems as part of their ongoing quality
nursing students during the administration phase and as improvement initiatives. Employees of participating
facilities enter, review, and then release the data to a
central data repository that is then available for all
Table 4. Factors Contributing to Student Medication Errors subscribers to search. Reports spanning from January 1,
(N = 1,305) 1999, to December 31, 2003, and involving student-made
Contributing Factors n %
Staff, inexperienced 593 77.71
Distractions 153 20.05 Table 6. Levels of Care Performed After Students’ Medication
None 60 7.86 Errors
Cross coverage 19 2.49
Care Performed n %
Shift change 17 2.22
Workload increase 12 1.57 None 484 63.68
Staffing, insufficient 7 0.91 Observation initiated/increased 139 18.28
Staff, agency/temporary 7 0.91 Vital signs monitoring initiated/increased 103 13.49
No access to patient information 6 0.78 Drug therapy initiated/changed 57 7.50
Emergency situation 6 0.78 Laboratory tests performed 48 6.31
Poor lighting 3 0.39 Antidote administered 5 0.65
Patient transfer 3 0.39 Transferred to a higher level of care 2 0.26
Staff, floating 2 0.26 Oxygen administered 2 0.26
No 24-hour pharmacy 2 0.26 Narcotic antagonist administered 2 0.26
Code situation 1 0.13 X-ray, computerized axial tomography, 1 0.13
No contributing factor reported 542 71.03 magnetic resonance imaging, or
Records in which contributing 763 58.46 other diagnostic test(s) performed
factors were reported Hospitalization, prolonged 1–5 days 1 0.13
Total no. of contributing 891 Records in which care performed was reported 760 58.23
factors reported Total no. of levels of care performed reported 844
44 WOLF ET AL

Table 7. Therapeutic Class of Medications Organized by Table 7. (continued)

Veterans Administration Code Involved in Student
Therapeutic Class Subtotal
Errors
Insulin 104
Therapeutic Class Subtotal Oral antidiabetic agents 29
Antihypoglycemics 1
Antidotes, deterrents, and poison control 6
Thyroid supplements 11
Antihistamines 21
Antithyroid agents 2
Antimicrobials (N = 137) 1
59 Hormones/synthetics/modifiers, Others
h-lactam antimicrobials 11
3 Vaccines
Macrolides 3
Toxoids
Aminoglycosides 4
Immunomodulators 3
Lincomycins 8
Antirheumatics 23
Quinolones 13
Skeletal muscle relaxants 7
Antituberculars 1
Neuromuscular blockers 1
Sulfonamide/related antimicrobials 2
Antigout agents 3
Antifungals 3
Musculoskeletal agents, Others 3
Antivirals 1
Nasal and throat agents, Topical 1
Anti-infectives, Others 43
Ophthalmic agents 21
Antineoplastics 1
Antiasthma/bronchodilators 56
Antiparasitics 1
Antitussives/expectorants 6
Autonomic medications 28
Mucolytics 2
Blood coagulation modifiers 63
Therapeutic nutrients/minerals/electrolytes 1
Blood formation 4
Intravenous solutions without electrolytes 6
Volume expanders 2
Intravenous solutions with electrolytes 1
Opioid analgesics 97
Enteral nutrition 1
Nonopioid analgesics 45
Lipid supplements 1
Anesthetics 4
Electrolytes/minerals 37
Sedatives/hypnotics/anxiolytics 16
Unclassified 6
Anticonvulsants 27
Vitamins 8
Antiparkinsonian agents 4
Miscellaneous agents 1
Antidepressants 28
Antipsychotics 15
Antimanic agents 2 errors in the administration phase of the medication use
CNS stimulants 2
process were downloaded. The errors were attributed to
CNS medications, Others 4
20
nursing students attending professional nursing pro-
Cardiac inotropic agents
h-Blockers/related 60 grams. All analyses were conducted at the USP.
a-Blockers/related 2
Calcium-channel blockers 25 Ethical Considerations
Antianginals 11
We requested and were granted permission to conduct the
Antiarrhythmics 11
16
study by the institutional review board of La Salle
Antilipemic agents
Antihypertensives 18 University. Data contained within the reports were
Diuretics 58 anonymous and de-identified according to the conditions
ACE inhibitors 37 for participation jointly agreed upon by the USP and the
Cardiovascular agents, Others 2 subscriber. Reporters are advised to avoid disclosing
Dermatological agents 1 individually identifiable health information, such as
Diagnostic agents 1 names of health care providers, patients, and health care
Antacids 10 facilities and dates of patients’ birth.
Laxatives/antidiarrheal agents 20
Antiulcer agents 38
3
Instrumentation
Inflammatory bowel disease agents
Digestants 1 Facilities participating in the MEDMARX are provided
Antiemetics 4 with a copy of the Medication Error Information Report,
Appetite stimulants 1 a medication incident report form constructed to match
Gastric medications, Others 12 the NCC MERP taxonomy (USP Dispensing Informa-
Anti-infectives, Vaginal 2 tion, 2003) on which to enter data after the occurrence
Oxytocics 1
of a medication error. Personnel of participating facil-
Labor suppressants 1
2
ities electronically enter error characteristics into the
Benign prostatic hypertrophy agents
Adrenal corticosteroids 13 MEDMARX through a series of structured data entry
Sex hormones/modifiers 7 fields that correspond to the Medication Error Informa-
Calcium-regulating agents 1 tion Report. Most fields are accompanied by a stan-
dardized pick list selection, from which a reporter
STUDENT–MADE DRUG ADMINISTRATION ERRORS 45

Table 8. Medications and Other Products Associated With Node This field identifies where the initial medication
NCC MERP Harm Categories error occurred in the medication use process (i.e.,
Product n % prescribing, transcribing/documenting, dispensing, ad-
ministering, or monitoring). Node is applicable to
Insulin4 5 17 Categories B and higher. This study focused only on
Ranitidine4 2 7 errors that involved the administering phase.
Morphine4 2 7
Fentanyl4 2 7 Types of Error This field provides the manifestation of
Sufentanil 1 3 an action that characterizes or represents the overall
Prednisone 1 3 description of a medication error. There are 13
Nitroglycerin4 1 3 medication error types included in the multiselect pick
Nateglinide 1 3 list (e.g., wrong patient, wrong time, omission error).
Nadolol 1 3
Midazolam 1 3 Causes of Error This field denotes the 63 causes asso-
Metronidazole 1 3 ciated with a medication error and is drawn from a
Losartan 1 3 multiselect pick list (e.g., brand names look alike,
Hydrochlorothiazide 1 3 abbreviations, handwriting illegible/unclear).
Guaifenesin 1 3
Furosemide 1 3 Contributing Factors This field comprises an 18-item
Fat emulsions 1 3 multiselect pick list that provides information about
Enoxaparin 1 3 factors that contribute to a medication error (e.g., poor
Enalapril 1 3 lighting, workload increase, emergency situation). Con-
Docusate calcium 1 3 tributing factors can be situational, environmental, or
Compounded drug 1 3 organizational influences that may predispose the
Captopril 1 3
occurrence of an error.
Atenolol 1 3
Records in which products were reported 22 Level of Care Rendered as a Result of the Error This
Total no. of products 29 multiselect field describes up to eight clinical aspects of
4Denotes that products have been grouped by dose form and strength. care that might be rendered after a medication error
occurs (e.g., observation increased, oxygen adminis-
tered, hospitalization prolonged). The data serve as
populates that field. Some fields are designed as a single-
select field, indicating that only one value could be
selected. Others are designed as multiselect fields, in- Table 9. Location of Medication Errors (N = 1,305)
dicating that more than one selection could be associ-
ated with the record. Few fields are bfree textQ fields that Location n
allow a reporter to submit pertinent information that Nursing (patient care) unit 1,034
corresponds to the medication error. For actual medi- Data not provided 68
cation errors, the reporter completes 10 fields if the Long-term care facility 47
error was intercepted and did not reach the patient or Emergency department 21
13 fields if the error actually reached the patient. Pediatrics 20
Intensive care unit, Medical 14
Error Category Index This field captures whether a med- Operating room 11
ication error occurred and, if it did, its effect on the patient Maternity 11
involved. In the NCC MERP (2001) Index for Catego- Intensive care unit, Surgical 10
rizing Medication Errors, Category A indicates circum- Oncology department 9
stances or events that have the capacity to cause an Intensive care unit, Coronary 9
error; Category B, a medication error occurred but it did Psychiatric 8
not reach the patient (i.e., intercepted); Category C, a Clinic, Outpatient 7
Psychiatric, Inpatient 6
medication error occurred but with no resulting patient
Rehabilitation care unit 5
harm; and Category D, an error that resulted in the need 5
Nursery
for increased patient monitoring but no patient harm Labor/delivery 4
occurred. The varying levels of patient harm are Intensive care unit, General 3
reflected in Categories E (error resulted in the need Cardiovascular/pulmonary services 3
for treatment or intervention and caused temporary Radiology department 2
patient harm), F (error resulted in initial or prolonged Hospital, Another 2
hospitalization and caused temporary patient harm), G Pharmacy, Inpatient 1
(error resulted in permanent patient harm), H (error Patient home/residence 1
resulted in a near-death event such as anaphylaxis and Obstetric recovery room 1
cardiac arrest), and I (error occurred that may have Intensive care unit, Neonatal 1
Emergency transport vehicle 1
contributed to or resulted in patient death) (NCC
Dialysis unit 1
MERP, 2001).
46 WOLF ET AL

surrogate markers for resources expended in response
to an error event.
Actions Taken This multiselect field contains 13 items
that document an organization’s response to a
medication error (e.g., informed staff who made
the initial error, policy/procedure changed, environ-
ment modified).
Products This field provides the generic (nonpropri-
etary) and/or brand (proprietary) name, manufacturer,
and therapeutic classification of the product(s) in-
volved in the medication error. Products associated with
records are entered by the users from the MEDMARX
product table and may reflect the product intended for
use, the product not intended for use, or both. When
applicable, product groupings that combine individual
products regardless of dose form, strength, and product
formulation have been performed.
Procedures for Data Collection
The USP collects data about medication errors that
have been directly entered into the MEDMARX
program by subscribing hospitals and health systems.
Custom-built search queries, using Crystal Report
Writer (Version 9), allowed for the identification
and subsequent analysis of errors involving students.
Each of the data fields previously described was
analyzed for the purposes of grouping and counting.
The data set used for this study remained static
to prevent alteration, deletion, or addition of records.
The USP maintains copies of all static databases on file
in Rockville, Maryland. One researcher (RH), with
expertise in data analysis and query building, extracted
all data.
Data Analysis
Data were reviewed to determine the characteristics of
medication errors made by students during the
administration phase of the medication use process.
Unique MEDMARX record numbers that met the
following criteria were identified: level of staff identi-
fied as having made the initial error was equal to
student; node (phase of the medication use process)
was equal to administering; and date submitted was
between January 1, 1999, and December 31, 2003. After
the unique record numbers were identified, data were
extracted from the remaining fields (type of error,
cause of error, contributing factor, product, location of

Table 10. The NCC MERP Error Category Index With Examples of Nonharmful Errors Made by Students
Error Category Index A B C D
Definition Circumstances An error occurred, but it An error occurred, An error occurred, and it
or events that have the did not reach the patient and it reached the reached the patient and
capacity to cause error patient but did not required monitoring to
cause harm confirm that it resulted in
no harm to the patient and/
or required intervention to
preclude harm
No. of cases reviewed 0 50 921 304
Error descriptions Student nurse took two Furosemide 60 mg (as Student nurse used wrong
from actual cases intravenous bags into the a liquid) was ordered patient’s blood sugar with
medication room. to be given to patient. a sliding scale and gave
Cefepime was scheduled Student nurse 12 U of insulin (instead of
at 14:00 hours and valpro administered 300 mg 9 U). Student nurse also
ate sodium was scheduled by mistake to the gave extra dose of regular
at 16:00 hours She spiked patient through the insulin at 21:00 hours
the valproate sodium bag gastrointestinal tube. (sliding scale intended to
thinking it was the be used only bwith
cefepime and noted the mealsQ).
error just as she was
about to leave the
medication room and walk
into the patient’s room.
Product(s) involved Cefepime and valproate Furosemide Insulin
sodium
Type of error Wrong time Improper Extra dose and improper
dose/quantity dose/quantity
Causes of error Performance deficit Calculation error Performance deficit
Similar packaging/labeling Performance deficit Communication
Contributing factor Distractions Staff, inexperienced Staff, inexperienced
Location of error Intensive care unit Nursing (patient care) Nursing (patient care) unit
unit
STUDENT–MADE DRUG ADMINISTRATION ERRORS 47

error, level of care rendered as a result of the error,
and actions taken) from the database.
Query output from the selected MEDMARX pro-
gram fields was then exported to Excel. Descriptive
statistics were calculated on the pick list selections
from each database field to determine the corres-
ponding percentage of selections. Content analysis
was performed on narrative responses associated with
each record.
Results
During the 5-year period, 1,305 student-made medica-
tion errors originating in the administering node were
reported to the MEDMARX. Table 1 shows the fre-
quencies and percentages for student errors on the NCC
MERP Index for Categorizing Medication Errors. Fewer
than 3% (n = 30) of the errors resulted in patient harm.
There were 1,208 records (92.5%) that were associated
with a type of error, which are summarized in Table 2.
Most medication errors were those of omission, fol-
lowed by those of administering the wrong amount of
medication. Of note is the high number of wrong patient
errors because this count is much higher than that
found in other USP studies (Hicks, Santell, Cousins, &
Williams, 2004). Some records included more than one
type of error selection.
Table 3 shows the causes of medication errors
identified from 1,135 records (~87% of the sample
identified at least one cause of error). Reporters to
the MEDMARX are offered 63 cause-of-error selections
from a multiselect pick list. The most prevalent cause

Table 11. The NCC MERP Error Category Index With Examples of Harmful Errors Made by Students
Error
Category
Index E F G H I
Definition An error that may have An error that may have An error An error that required An error
contributed to or contributed to or that may intervention necessary that may
resulted in temporary resulted in temporary have to sustain life occurred have
harm to the patient harm to the patient contributed contributed
and required and required initial or to or to or
intervention prolonged resulted in resulted in
occurred hospitalization permanent the patient’s
occurred patient harm death
occurred occurred
No. of cases 28 1 0 1 0
reviewed
Error Nursing student Student nurse did not A patient had
descriptions checked medications give morning doses of morphine sulfate
from actual with staff member. blood pressure ordered three times a
cases Student waited to medications. Staff day at 8-hour intervals.
administer medications nurse thought student The student nurse gave
while the intravenous had given the an extra dose prior to
team placed new medications. The the next scheduled
intravenous catheter in patient became interval. The patient
the patient’s left hypertensive and developed significant
forearm. Instructor developed chest pain respiratory depression
entered room and and subsequently had a and had to be
noticed instantly that myocardial infarction. intubated and
student was The patient had to be transferred to a higher
administering transferred to a higher level of care.
guaifenesin through the level of care.
intravenous line
instead of the feeding
tube.
Product(s) Guaifenesin Atenolol, captopril, Morphine sulfate
involved furosemide, and
losartan
Type of error Wrong route Omission Extra dose
Cause of error Performance deficit Communication Performance deficit
Contributing Staff, inexperienced Staff, inexperienced Staff, inexperienced
factor
Location of Nursing (patient care) Nursing (patient care) Nursing (patient care)
error unit unit unit
48
was students’ performance deficits. Some records
contained more than one selection. Table 4 shows
factors contributing to the drug errors. Staff, inexperi-
enced was the leading contributing factor, followed by
distractions. Table 5 shows that the highest action
taken was that students were informed of error events
and received educational interventions regarding
the errors.
Table 6 shows the level of care performed for patients
after an error. More than 60% of the errors had no care
performed afterward, indicating that most patients were
not harmed or evidenced no observable outcome. The
most frequently performed care was that of observation
initiated/increased, with vital signs monitoring initiated/
increased being the second most frequent. Those
selections with the lowest frequencies were most likely
associated with harmful errors.
Table 7 shows the reported products’ therapeutic
class of medications using the Veterans Administration
Code taxonomy (USP Dispensing Information, 2003).
There were 316 unique products reported to have been
involved in medication errors committed by students
in the administration phase. The therapeutic class of
antimicrobials (and the 10 subcategories within this
class; n = 137) was the most commonly reported. The
next highest class reported was that of opioid
analgesics (n = 97). Insulin (n = 106) was the most
frequent single medication reported of the student
administration errors. Several of the medication errors
reported in case records involved two or more
products at the time of the error.
Table 8 shows the medications and other products
identified in events associated with harm to patients. Of
the 22 reports (8 reports did not specify a product) in
which harm was reported, insulin was the most
frequently noted drug (n = 5, 17%). Table 9 shows the
locations where students made the errors. Most oc-
curred in hospital settings. Tables 10 and 11 show
examples of nonharmful and harmful errors organi-
zed by the NCC MERP Index for Categorizing Medica-
tion Errors.
Discussion
We examined medication errors involving students that
occurred during the administration phase of the
medication use process. Based on the analysis of 1,305
error records, we concluded that medication errors
involving students during the administration phase may
be more widespread than previously thought. The
findings also demonstrate that students have been
implicated in errors resulting in harm to patients.
Relatively few (n = 30) of the errors resulted in harm;
this is consistent with the percentage of harm reported
in all of MEDMARX records during the same period
(Hicks et al., 2004).
Approximately one third of the errors involved
omission and administration of the wrong dose
(amount) of medication. The two most commonly
WOLF ET AL
reported types of errors (omission error and improper
dose quantity) for students are the same types of errors
seen in the entire MEDMARX data set. Wrong time, as a
type of error, occurred in 17% of the student records;
this is nearly three times more than wrong time (6.8%)
in the overall MEDMARX data set. The use of military
time, a 24-hour time specification as opposed to
expressing time in the 12-hour format (a.m. or p.m.),
was involved in several cases. This was interpreted to
mean that some students had difficulty with time
conversions. One case reviewed indicated that a student
(on the first day of clinical experience) was unable to
correctly interpret the times printed on the medication
administration record. In another case, a student was off
the unit for lunch and was late in administering the
noon medications. Multiple records indicated that
warfarin was to be given daily. Several institutions
schedule this administration time at 17:00 hours to
allow for dose adjustments. Many of the records
reviewed indicated that students administered the drug
with the other daily medications at 09:00 hours.
Wrong patient errors (9.19%) were higher than those
reported in another USP study (4.9%; Hicks et al.,
2004), signaling that patients were incorrectly identified
before medication administration, a finding that is
counter to the Joint Commission on Accreditation of
Health Care Organizations [JCAHO] (2004) national
patient safety goal of ensuring proper patient identifi-
cation. One case indicated that a patient had refused
medications and the drugs were left on the medication
cart. The student proceeded to administer them to
another patient. Many of the wrong patient errors
occurred in semiprivate rooms with two patients:
medications intended for one patient were inadvertently
given to the other occupant.
Wrong route errors (3.6%) involving students were
much higher than wrong route errors reported in
another MEDMARX study (Hicks et al., 2004). One
case indicated that cough syrup intended for oral
administration was actually administered intravenously
by a student.
The most prevalent cause of errors was the perfor-
mance deficits of students, seen in more than half of the
records identifying the cause. Performance deficit implies
that a student had the requisite skills and knowledge to
safely perform medication administration but failed to
discharge duties successfully. The next highest causes
were procedure/protocol not followed (32%), knowledge
deficit (26.5%), and communication (17%). These four
causes of errors together were more often associated with
students than the overall MEDMARX data set (Hicks
et al., 2004).
The chief factor leading to the errors was attributed
to students’ inexperience and represented approximate-
ly three quarters of the records that indicated a
contributing factor. When grouped with the second
most commonly reported contributing factor, distrac-
tions, these findings are not surprising. Students are
beginning to acquire the skills necessary for safe
STUDENT–MADE DRUG ADMINISTRATION ERRORS
medication administration and may not be able to
perform multiple tasks simultaneously or to prioritize
successfully. Faculty might consider bringing into
sharper focus the many distractions in clinical situations
that deter students from safe medication administration.
After administration errors were made, patients were
observed increasingly and their vital signs were moni-
tored more often. Other interventions that were
reported could consume more expensive resources.
For example, prolonged hospitalization, transfer to a
higher-level care setting, and additional laboratory or
diagnostic tests performed as a result of medication
errors result in increased costs.
Hicks et al. (2004) noted that a total of 1,559 unique
products was reported as being involved in errors
during 2003. In this study, there were only 316
products involved in errors with students during the
administration phase over a 5-year period. Both findings
are representative of the vast number of products with
which nurses must be familiar and illustrate the wisdom
of faculty recommending that students have rapid access
to current drug references through personal digital
assistants while medications are administered (Huffstu-
tler, Wyatt, & Wright, 2002; Lewis & Sommers, 2003;
Peterson, 2003).
Recommendations
Nursing faculty might reconsider the medication ad-
ministration experiences of students and medication
safety in light of these findings. For example, basic
nursing education programs could provide or require
students to purchase personal digital assistants, loaded
with pharmacology textbooks and dose and intravenous
flow rate calculation software and convenient for
students and faculty reference, at the point of medica-
tion administration. Ready access to drug information
might prevent errors. Students should have uninter-
rupted access to faculty during medication administra-
tion times. In addition, the JCAHO (2004) guideline on
patient identifiers needs to be emphasized repeatedly by
faculty, nursing staff, and students.
Concerns about wrong time errors of students should
prompt nursing educators to call students’ attention to
this problem during courses when medications are
administered. Emphasis might be placed on checking
patients’ medication (Kardexes) and physician or nurse
practitioner orders at least every 2 hours. Omission
errors are worrisome; nursing faculty, nursing staff, and
students should evaluate the attention given to verbal
reports about the medications that have been adminis-
tered before students leave nursing units.
Faculty and nursing staff may wish to reexamine the
processes and circumstances associated with medica-
tions administered by nursing students. Curriculum
revision addressing medication administration safety
seems warranted to integrate elements of medication
safety and the medication use process across a program
of studies. Medication safety knowledge and skills
49
might be outcomes that are incorporated throughout
each course in the curriculum and linked directly to
other didactic and clinical experiences. More detail
might be included on ordering and dispensing systems
coupled with the traditional five rights, intensified
preparation for medication administration prior to
clinical experiences by studying drugs to be given,
presentations on dangerous abbreviations and prescrip-
tion elements, and discussions on high-risk medica-
tions. Nursing faculty might also examine the trend in
health care agencies of creating a nonpunitive culture
that seeks to learn from mistakes rather than punish
individuals involved in medication and other health
care errors. It is important to openly report students’
medication errors. A nonpunitive culture has been
linked with more errors reported, thus creating
opportunities to prevent future errors.
Health care organizations that allow students to
administer medications might review the extent
to which nursing faculty and students are oriented to
the policies and procedures of these organizations’
medication use process, especially as they pertain to
the administration of medications. Medication admin-
istration laboratory sessions that include simulated
clinical situations using physician orders, medication
records, simulated medications, patient identification
bands, narcotic boxes, and narcotic administration
sheets would be helpful in reinforcing safe medication
administration principles. Few nursing education pro-
grams have the resources to develop clinical simula-
tion laboratories that use automated dispensing
devices and computerized medication administration
records. Staff development departments should sup-
port student learning by bridging didactic learning
with the clinical applications of this technology.
The findings of this study should be viewed with
caution because the data collected within MEDMARX
were voluntarily reported by subscribing hospitals and
their related health systems and may not be represen-
tative of administration-phase medication errors involv-
ing students. However, the benefit of the reporting
program is that it draws upon the experience of multi-
ple facilities.
Future research could focus on medications errors
made by students and reported to the MEDMARX
through a database that includes more elements such
as the type of nursing education system that a student
was attending, method of medication calculation in-
struction, and whether a faculty or preceptor was
supervising the student. Knowledge of the character-
istics of students’ medication errors could assist faculty
in shaping curricula within the contexts of current
safety initiatives, medication use processes, and the
patterns evident in student errors.
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