Medication Error Prevention

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Contact Hours: 2

This online independent study activity is credited for 2 contact hours at completion.

Course Purpose

To provide healthcare professionals with knowledge of medication errors and review strategies to reduce the risk of a medication error.

Overview

More than 100,000 medication errors are reported to the Food and Drug Administration each year. Medication errors occur because of environmental factors, unavailable medication information, and miscommunication of medication orders. There are many identifiable ways to reduce mediation errors, such as using the 6 rights to medication administration, medication reconciliation, and verifying new orders through double checking and read back techniques. Medication errors are preventable, and often result from not following proper policies in place for medication administration. This learning activity identifies potential risk factors that contribute to medication errors, and solutions that may be implemented when administering medication to reduce the risk of medication errors.

Objectives

Upon completion of the reading content, the healthcare professional will be able to:

  • Define medication error
  • Identify factors that can cause medication errors
  • Identify solutions to reduce the risk of medication errors

Policy Statement 

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Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

Fast Facts: Medication Error Prevention

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Case Study

Melinda Thomas is a new graduate nurse who was recently hired onto the Medical/Surgical (Med-Surg) unit. Today is her first day off preceptorship and she is about to administer mediations to one of her patients. Maria Garcia is one of the patients assigned to Melinda. She has been admitted for cellulitis and is scheduled to receive a dose of antibiotics. After gathering all the medications timed for 0900, Melinda goes into Maria Garcia’s room. Upon arrival to the room, Melinda states “Hello Mrs. Garcia, I have your medications”. Mrs. Garcia responds by saying “Thank you”. Melinda hands Mrs. Garcia, her medications and Mrs. Garcia states “These look different. Did my doctor change my medication?” Melinda responds by saying “Sometimes the way the medications look can change, depending on who the manufacturer is. These are the medications that your doctor prescribed to you.” Mrs. Garcia then says “OK” and proceeds to take all the medications. After administering the medications to Mrs. Garcia, Melinda prepares to document all the medication. She then realizes that she administered the medications to the wrong patient, as there is another Maria Garcia on the unit. How did Melissa identify Mrs. Garcia, and what should she have done to identify the correct patient?

Case Study Response

Melinda did not identify Mrs. Garcia at all. She greeted Mrs. Garcia and proceeded to attempt to administer the medications to her. To reduce the risk of medication errors, Melinda should have utilized the 6 rights of medication administration which include:

  • Right patient (through two identifiers, such as name, date of birth, medical record number, etc.)
  • Right medication
  • Right route
  • Right dose
  • Right time
  • Right documentation
Introduction

Accurate and safe medication administration depends a healthcare provider’s pharmacologic knowledge, decision making, and critical thinking skills. Consequently, medication administration is a high-risk task, as medication errors can result in poor patient outcomes. These errors may occur during any phase of the medication process, including when prescribed, transcribed dispensed, and administered.

Medication Errors

Medication errors can have serious and costly consequences, such as increased patient lengths of stay, additional medical interventions, serious harm, or even death. These errors can occur at any point during mediation usage, such as when it is prescribed, dispensed, and administered. Each year the food and drug administration (FDA) receives more than 100,000 reports regarding medication errors. Medication errors can result in birth defects, disability, prolonged hospitalization, a life-threatening situation, and death.

To reduce the risk of medication errors, the FDA reviews a new mediation’s name, packaging, and labeling. If a correction is required, the FDA will suggest a revision prior to approving a new medication. After a medication is approved for marketing, the FDA monitors for medication error reports regarding the new medication. The FDA may again, request revisions to packaging and labeling of a new medication and may issue a communication alert to the public about a medication error safety issue through the drug safety communications, drug safety alerts, and medication guides.

Although the FDA attempts to reduce the risk for medication errors prior to medication approval, medication errors still exist. The American Hospital Association lists the following as common factors that contribute to medication errors:

  • Unavailable patient information, such as not knowing about a patient’s allergies, drug contraindications, diagnoses, and lab values.
  • Unavailable drug information, such as having a lack of up-to-date warnings and pharmacist consultation.
  • Miscommunication of drug orders caused by poor handwriting, confusion between drugs with similar names, improper of zeroes and decimal points, confusion over metric or other dosing units, and use of inappropriate abbreviations.
  • Drug standardization, storage, and stocking. For instance, causing confusion that arises from stocking multiple concentrations of the same drug or storing drugs in look-alike containers or in ways that obscure drug labels.
  • Environmental factors such as lighting, heat, noise, and interruptions that can distract healthcare providers when transcribing orders.
  • Limited education of healthcare providers in awareness of error-prone situations.
  • Limited patient education
  • Inadequate systems for identifying, reporting, analyzing, and correcting errors, and identifying trends, and cultivating a non-punitive attitude towards a medication error.

To ensure medication safety, nurses are often the last ‘gatekeepers’ in the administration process of a drug to prevent medication errors. As such, it is important to take the necessary steps to ensure patient safety, and to minimize distractions throughout the medication administration process. The following concepts have been identified to prevent medications errors.

Follow the six rights of medication administration

The six rights to medication error include⁷:

  • Right Patient
    • Medication errors often occur because a medication intended for one person is administered to another. To prevent the occurrence, the healthcare provider must follow the healthcare facility’s policy on identification, which is most often checking the medication record and the type of identification utilized at the healthcare facility; such as an identification band name, medical record number, date of birth, etc.
  • Right Medication
    • Medication orders and medication labels must be read correctly to ensure that the intended medication for administration is correct. A pharmacist, physician, or nurse with prescribing authority must be notified if the order and the label of the drug do not match. The expiration date of the medication must also be checked prior to administration, and if the medication is unfamiliar, a drug book or pharmacist should be consulted.
  • Right Dose
    • The healthcare provider must compare the dose of medication ordered to the dose of medication that is available for administration. If the medication requires calculation, the calculation should be double-checked with another healthcare provider. The correct dose range of medication can also be verified in a reputable drug book.
  • Right Time
    • Is the medication ordered for a specific time? The healthcare provider who is administering the medication must understand why a medication is administered during a certain time of day; for instance, why insulin is administered prior to a meal. The healthcare provider must also verify the time that the mediation is ordered for administration. If the medication is ordered for the appropriate time of administration, it would be administered according to the facilities policy of medication administration, usually within 30 minutes of the order administration time.
  • Right Route
    • The healthcare provider must verify the drug route (oral, intramuscular, intravenous, etc.) prior to administration. If the route of medication is not listed in the order, the healthcare provider must notify the prescriber to correct the order.
  • Right Documentation
    • There have been many medication errors that have resulted from incorrect documentation. “Right Documentation “has been added to the rights of medication administration to reduce the rate of medication errors. Documentation must include the patient’s name, the name of the medication ordered, the medication dose, route, frequency, and the time that it was administered. After administration, the medication administration record (MAR) must be updated per facility policy.
Follow Proper Medication Reconciliation Procedures

Medication reconciliation is an important patient safety issue. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), a private, nonprofit organization whose mission is to continuously improve the safety and quality of care provided to the public, instituted the National Patient Safety Goals (NPSG) to reduce medication errors and improve quality assurance and patient safety.⁴ The NPSG focuses on the risk points of medication reconciliation. During medication reconciliation, the healthcare provider compares mediations that are currently prescribed to new medications that are ordered and resolves any discrepancies. The comparison addresses medication order duplications, omissions, medication interactions, and the need to continue current medications. The types of information that healthcare providers must use to reconcile medications include the medication name, dose, route, frequency, and purpose. JCAHO included five elements of performance for NPSG, which include the following:

  • Obtain a list of medications that the patient is currently taking.
  • Define the location (emergency room, outpatient services, ambulatory care, etc.) and the types of medication information that is collected, such as the medication name, dose, route, and frequency.
  • Compare the medication information provided by the patient to the medications ordered to identify and resolve discrepancies.
  • Provide the patient or caregiver with written information on the medications (name, dose, route, frequency, purpose) the patient should be taking.
  • Explain the importance of managing medication information to the patient or caregiver.
Double Check Prior to Medication Administration

The double check should be conducted independently by a second healthcare provider to reduce the risk of bias that can occur when a healthcare provider who prepares and checks the medication sees what they expect to see. ⁴ An independent double check requires two healthcare providers to check each component of the work process separately. For instance, a healthcare provider, calculates a dose of an intravenous medication, prepares a syringe of medication, and compares the medication to the order. A second healthcare provider then independently checks the medication order, calculates the medication dose, and compares the order to the medication prepared by the first healthcare provider. This system is effective, because two healthcare providers are unlikely to make the same mistake if they work independently.

Verify a Verbal Order Through Read Back

Read back of a verbal order has long been practiced by the healthcare industry to reduce miscommunication when medical orders are relayed over the phone.⁵ To improve continued reduction in medication errors, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) included read back of verbal orders on its list of patient safety goals. According to JCAHO, whenever a verbal order is made, the healthcare provider on the receiving end must first document the order on paper or in a computer system and then read it back to ensure verbal order accuracy. This practice ensures that the healthcare provider who received the information has not only heard an order correctly but also transcribed it accurately. Elements of a verbal order should include the patient name, age, and weight (if needed for dose calculation), drug name, dosage, strength or concentration, frequency, duration, and purpose or indication for usage. The prescriber of the medication should then verify the verbal order in the patient’s chart and sign the order within the timeframe defined by the facility.

Use a Name Alert for Common Names

Many facilities use name alerts to prevent mediation errors resulting on patients with similar sounding patient names. For instance, similar names Smith and Smythe can result in medication error because of administering the medication to the wrong individual. ⁴ To prevent the confusion, many facilities place name alerts on patient’s charts, medication administration record (MAR), and on identification bands. It should also be noted, that in most facilities, two identifiers (name, date of birth, medical record number, etc.) are required prior to administering a medication.

Place a Zero in Front of the Decimal Point

Errors in the dosage and strength of medications have occurred because of the misinterpretation that results from an absence of a leading zero in front of a decimal point such that .5 mg can be interpreted as 5 mg. ⁸ Also, the presence of a trailing zero behind a decimal point in numbers that are greater than 1 can result in a medication error; 5.0 mg can be interpreted as 50 mg.

Aside from medication errors from decimal point placement, medication errors have also resulted from illegible orders. For instance, a number or letter could be read or interpreted differently than intended, even in computerized form, such as misinterpreting the capital letter “I” with the number “1”, or the capital letter “O” with the number “0”. To reduce the risk for errors, the healthcare provider should document drug names in capitalized form and dosages in the metric system, whenever possible. Documenting in this form will likely help reduce miscalculations when converting to the metric system, since the metric system is used for product labeling.

Other errors found have been in use of abbreviations and symbols because they can be misunderstood. The following list from consumer med safety lists common abbreviations that could cause a medication error³:

AbbreviationIntended MeaningMisinterpretationCorrection
μgMicrogramMistaken as “mg”Use “mcg”
AD, AS, AURight ear, left ear, each earMistaken as OD, OS, OU (right eye, left eye, each eye)Use “right ear,” “left ear,” or “each ear”
OD, OS, OURight eye, left eye, each eyeMistaken as AD, AS, AU (right ear, left ear, each ear)Use “right eye,” “left eye,” or “each eye”
BTBedtimeMistaken as “BID” (twice daily)Use “bedtime”
ccCubic centimetersMistaken as “u” (units)Use “mL”
D/CDischarge or discontinuePremature discontinuation of medications if D/C (intended to mean “discharge”) has been misinterpreted as “discontinued” when followed by a list of discharge medicationsUse “discharge” and “discontinue”
IJInjectionMistaken as “IV” or “intrajugular”Use “injection”
INIntranasalMistaken as “IM” or “IV”Use “intranasal” or “NAS”
HS

hs
Half-strength

At bedtime, hours of sleep
Mistaken as bedtime

Mistaken as half-strength
Use “half-strength” or “bedtime”
IU**International unitMistaken as IV (intravenous) or 10 (ten)Use “units”
o.d. or ODOnce dailyMistaken as “right eye” (OD-oculus dexter), leading to oral liquid medications administered in the eyeUse “daily”
OJOrange juiceMistaken as OD or OS (right or left eye); drugs meant to be diluted in orange juice may be given in the eyeUse “orange juice”
Per osBy mouth, orallyThe “os” can be mistaken as “left eye” (OS-oculus sinister)Use “PO,” “by mouth,” or “orally”
q.d. or QD**Every dayMistaken as q.i.d., especially if the period after the “q” or the tail of the “q” is misunderstood as anUse “daily”
qhsNightly at bedtimeMistaken as “qhr” or every hourUse “nightly”
qnNightly or at bedtimeMistaken as “qh” (every hour)Use “nightly” or “at bedtime”
q.o.d. or QOD**Every other dayMistaken as “q.d.” (daily) or “q.i.d. (four times daily) if the “o” is poorly writtenUse “every other day”
q1dDailyMistaken as q.i.d. (four times daily)Use “daily”
q6PM, etc.Every evening at 6 PMMistaken as every 6 hoursUse “6 PM nightly” or “6 PM daily”
SC, SQ, sub qSubcutaneousSC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery)Use “subcut” or “subcutaneously”
ssSliding scale (insulin) or ½ (apothecary)Mistaken as “55”Spell out “sliding scale;” use “one-half” or “½”
SSRI

SSI
Sliding scale regular insulin

Sliding scale insulin
Mistaken as selective-serotonin reuptake inhibitor

Mistaken as Strong Solution of Iodine (Lugol’s)
Spell out “sliding scale (insulin)”
i/dOne dailyMistaken as “tid”Use “1 daily”
TIW or tiw3 times a weekMistaken as “3 times a day” or “twice in a week”Use “3 times weekly”
U or uUnitMistaken as the number 0 or 4, causing a 10-fold overdose or greater (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dose given in volume instead of units (e.g., 4u seen as 4cc)Use “unit”
Document Appropriately

Medications should be documented as being administered on the appropriate documentation tool approved by the facility. To reduce the risk of a medication error, the medication record should never be altered. The healthcare provider should not erase, obliterate, or attempt to edit any note with correction fluid or tape that has been previously written. Instead, a correction or late entry should be clearly marked and documented by drawing a single line through the error, writing the word “error” above the error, and then initialing the error. Late entries, entries made out of time sequence, or an addendum should be clearly marked as such in the record, properly dated, timed, and signed. ⁷


Once a medication is administered, a patient’s response to the medication must also be documented when appropriate, such as when an as needed medication (PRN) is administered. The documentation must also identify any possible adverse reactions to the medications administered. Documentation of an explanation must also be written, such as “patient refusal” when a dose of an ordered medication is not administered

Store Medications Correctly

Ensuring proper storage of medications will assist in maintaining their efficacy until expiration. At the time of expiration, most drugs have 90% efficacy. The following suggests proper storage of medications within a facility.
All medications should be organized and stored in specifically designated cupboards, cabinets, closets or drawers that are able to maintain the appropriate temperature, humidity, and light so that the strength, quality, and purity of the medication is not affected. Medications in liquid, tablet, capsule, or powder form that are for external use should be stored separately from medications for internal use. ²˒⁵ Likewise, narcotics, prescription pads, and needles must be securely stored in a lockable space that is only accessible to authorized healthcare providers. Room temperature drugs should not be stored above 86 degrees Fahrenheit (30 degrees Celsius). Refrigerable medications should be refrigerated at a temperature between 35 degrees Fahrenheit (2 degrees Celsius) and 46 degrees Fahrenheit (8 degrees Celsius). Medications requiring freezing should be stored at 5 degrees Fahrenheit (-15 degrees Celsius) or lower. Refrigerator and freezers used to store medications must have daily temperature readings documented. All medications should be prepared in a clean area away from germicides, disinfectants and other household substances, and all multiuse medications must have an expiration date documented on the label.

Eliminate Distractions

Interventions that can be used to decrease distractions can reduce the risk of medication errors. Many healthcare facilities have implemented the sterile cockpit rule, which means eliminating distractions during medication preparation to avoid medication errors. This strategy was first developed and implemented by the airline industry in the 1980s to preserve safety in the cockpit area by preventing nonessential activities or conversations during the critical phase of flight. In relation to healthcare, the healthcare provider would be able to prepare medications in an uninterrupted environment. To encourage this technique, many facilities have designated a “quiet zone” for medication preparation.⁸

Learn the Facility’s Polices on Medication

The healthcare provider must follow the facility’s medication policies, and therefore must become familiar with the content of them. ⁸ The policies often contain information regarding the facility’s practices on medication ordering, transcription, administration, and documentation. Healthcare providers can also become familiar with guidelines on Blackbox medications, and look-a-like and sound-a-like medications.

Use a Drug Book

Drug guides are valuable in providing important information on medications, including trade and generic names, dosage ranges, side effects, adverse effects, drug-to-drug interactions, and drug precautions such as “take with meals”, or “do not crush”.⁶˒⁹ There are multiple pocket-sized references available that can be used by the healthcare provider to reference unfamiliar or uncommonly administered medications.

Conclusion

To safeguard against medication errors, healthcare providers must implement the proper procedures for medication administration, including using the six rights and completing accurate documentation once the medication is administered. Failure to record the medication administered increases the risk of a repeat dose being administered. Healthcare providers should be cautioned to not document the dose before the medication is given. This alone can cause a medication error because the patient may not receive the medication. Medication errors are preventable events. Safe medication practices, adequate resources, a work environment free from interruptions, and a nonpunitive approach to error reporting should be encouraged. Utilizing any or all the above strategies can help to prevent or reduce medication errors.

References
  1. 10 strategies for preventing medication errors. (2018, August 13). Retrieved from https://minoritynurse.com/10-strategies-for-preventing-medication-errors/
  2. Billstein-Leber, M., Carrillo, C. J., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy75(19), 1493-1517. doi:10.2146/ajhp170811
  3. Gold, J. (2020). Unsafe medical abbreviations – Consumer med safety. Retrieved from https://www.consumermedsafety.org/tools-and-resources/medication-safety-tools-and-resources/know-your-medicine/unsafe-medical-abbreviations
  4. Independent double checks: Undervalued and misused: Selective use of this strategy can play an important role in medication safety. (2020). Retrieved from https://www.ismp.org/resources/independent-double-checks-undervalued-and-misused-selective-use-strategy-can-play
  5. Minimizing medication errors: Communication about drug orders – 2016. (2016). Retrieved from https://www.aao.org/patient-safety-statement/minimizing-medication-errors-communication-about-d
  6. The nurse’s role in medication error prevention. (2016). Retrieved from https://www.rn.com/nursing-news/nurses-role-in-medication-error-prevention/
  7. The six rights of medication administration. (n.d.). Retrieved from https://nurseed.blogspot.com/2011/03/six-rights-of-medication-administration.html
  8. To prevent ordering errors, one hospital is bringing “read backs” to the bedside. (2019, June 17). Retrieved from https://www.todayshospitalist.com/To-prevent-ordering-errors-one-hospital-is-bringing-read-backs-to-the-bedside/
  9. Working to reduce medication errors. (2019, August 23). Retrieved from https://www.fda.gov/drugs/drug-information-consumers/working-reduce-medication-errors
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