About this course:
This course aims to elucidate the risks of medication errors and their impact on patient outcomes for nurses.
This course aims to elucidate the risks of medication errors and their impact on patient outcomes for nurses.
Upon completion of this activity, learners should be able to:
- discuss the incidence of medication errors
- identify common types of medication errors
- understand a nurse's role and responsibilities in preventing medication errors
- utilize root cause analysis (RCA) in the identification of medication errors
- identify high-risk medications
- recognize the crucial aspects of professional identity
Medication errors are a leading cause of avoidable harm in health care. Medication errors occur in both inpatient and outpatient care settings. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, 2022) defines a medication error as
Any preventable event that may cause or lead to inappropriate 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 products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use (para. 1)
Medication errors can increase the length of a hospital stay, the rates of hospitalizations and emergency room visits, the cost of care, and morbidity and mortality rates (Rasool et al., 2020; World Health Organization [WHO], 2022).
Many medication errors occur during a transition of care. During hospitalization, an individual's medication regimen is often changed or adjusted, including the medications used, dosage, or frequency. Poor communication, a lack of patient education and understanding, poorly written discharge instructions, and a hurried discharge process can increase the risk of medication errors. Although electronic prescriptions can be more convenient, the lack of a paper, tangible prescription may indicate to some patients that they do not have any new medication orders. An estimated 53% of adult and elderly patients experience a medication error or medication discrepancy following discharge from the hospital (Alqenae et al., 2020).
Prevalence of Medication Errors
Globally medication errors account for 1% of the total healthcare spending. This number does not include the cost of lost wages or productivity due to medication errors. Worldwide, medication errors account for 5% to 41.3% of all hospital admissions and 22% of readmissions following discharge from the hospital. This broad range of hospital admissions attributed to medication errors is due to the various methods used for classifying medication errors and prescribing practices. Many outpatient medication errors are due to prescribing an unnecessary drug, a non-optimal drug, or a non-optimal dose. In the US, medication errors affect over 7 million patients a year. Approximately 500,000 medication errors occur daily, resulting in 7,000 to 9,000 deaths annually. In the US, more people die because of medication errors than in motor vehicle accidents, breast cancer, or autoimmune disorders. Approximately $40 billion is spent each year in the US on patients affected by medication errors. Due to inconsistencies in reporting, the prevalence of medication errors varies based on the source (Rasool et al., 2020; Tariq et al., 2022; WHO, 2022).
The following is an abbreviated list of commonly used terms and their meanings:
- active error: occurs between an individual and an aspect of the larger health system; a front-line clinician makes these errors (e.g., administering the wrong drug)
- adverse drug event (ADE): occurs when a medication error reaches a patient and leads to harm
- adverse drug reaction: a reaction or negative outcome of medication administration at the recommended dose; these reactions are not common but expected due to the pharmacological action of the medication; they are not always preventable and therefore are not considered a medication error
- adverse event: a type of injury experienced by a patient; only avoidable adverse events are considered a medical error
- latent error: a failure of organization or design, including systems, policies and procedures, or equipment; it often goes unnoticed without any detectable harm; when an active error occurs, it can uncover an unrecognized latent error (i.e., an accident waiting to happen)
- medical misadventure: includes adverse drug reactions, ADEs, and medication errors; it occurs through omission or commission of medication administration (explained below) and is always undesirable
- near miss: any event that could have potentially led to an adverse event or patient harm but did not, either due to chance or some intervention; these situations provide opportunities for system and process improvements and should receive the same level of follow-up as an adverse event
- negligence: failure to meet or provide the expected standard of care
- never event: an error that should never happen if standard practices are followed
- sentinel event: an event that results in death or severe permanent or temporary harm to a patient; once discovered, sentinel events require immediate investigation into the cause (Agency for Healthcare Research and Quality [AHRQ], 2019; Rodziewicz et al., 2022; Tariq et al., 2022)
Types of Medication Errors
There are two major types of errors: errors of omission and errors of commission. Errors of omission occur when an action is not taken, such as not administering medication when ordered or indicated based on a patient's condition. Errors of commission occur when a medication is administered that is not ordered or is contraindicated for the patient. An example would be administering amoxicillin to a patient with a penicillin (PCN) allergy (Rodziewicz et al., 2022).
Medication errors can occur at any stage of the medication use process. The Joint Commission (TJC), WHO, and NCCMERP divide medication errors into taxonomies based on the source of the error. One source of error is improper storage leading to the deterioration or contamination of the drug. Errors can also occur during the prescribing phase. Another source of error is during the utilization stage. This includes errors that occur during dispensing, administration, and monitoring stages. Medication errors are frequently the result of system failures and human error (Tariq et al., 2022). The most common system errors are:
- incorrect order transcription
- failing to verify orders completely
- poor dissemination of medication education
- neglecting to verify patient allergy information or history
- a lack of interdisciplinary communication (Tariq et al., 2022)
Human error often results from fatigue, poor communication or hand-off, and inadequate staffing (WHO, 2022). The most common human errors that cause medication errors include:
- failure to communicate orders
- illegible handwriting
- wrong drug selection when ordering electronically
- confusing similarly named drugs
- choosing the wrong medication when packaged similarly
- selecting the wrong dose
- administering the medication via the wrong route, at the wrong time, to the wrong patient, or at the incorrect infusion rate or dose
- administering an additional dose or omitting a dose
- not following established protocols; utilizing workarounds
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Medication errors can also be categorized based on if they are rule-based, memory-based, knowledge-based, or action-based (Ambwani et al., 2019):
- Rule-based errors occur when nurses use a bad rule or misapply a good one. An example of a failure to apply a good rule is a nurse who hangs a bag of total parenteral nutrition (TPN) without cross-checking the ingredients with the current physician's order or asking a second nurse to perform a double-check. The application of a bad rule might be a facility that does not have an established policy requiring double-checks of TPN before patient administration. Either situation could result in a poor patient outcome. This type of error can be avoided through proper training and education and the consistent implementation of existing rules (e.g., policies and procedures).
- Memory-based errors occur due to memory lapses. An example is a nurse who administers PCN to a patient they know has an allergy to PCN but simply forgets. This type of error can be avoided with computerized prescribing systems and cross-checking allergies with each medication administration.
- Knowledge-based errors occur when nurses are missing information. An example is administering PCN to a patient without first establishing whether they have an allergy. This type of error can be avoided through appropriate intake of information on admission and utilizing computerized prescribing systems that track patient information so that pharmacists, providers, and nurses can cross-check each other.
- Action-based errors or slips are primarily due to carelessness during routine prescribing, dispensing, or administering medications. Examples include a pharmacist adding the wrong amount of potassium chloride into an IV bag due to distractions; a nurse who draws up 5 mL of a medication rather than 0.5 mL into a syringe because they were rushed while preparing the medication; or a nurse who overrides the electronic dispensing system to dispense a medication believing it to be required, not realizing that the provider had discontinued it earlier. This type of error can be avoided by minimizing distractions, cross-checking orders with a second nurse, following the rights of medication administration, and using bar codes.
Patients at Risk for Medication Errors
Specific patient populations are more at risk of experiencing a medication error than others. Those most at risk are individuals who take more than five medications (polypharmacy), have multiple comorbidities, have a chronic illness, see multiple providers, are over 65, and have poor health literacy. The risk of experiencing a medication error when taking five or more prescription medications is 30%. Individuals over 75 have a 38% chance of experiencing a medication error. Patients with developmental delays, mental health conditions, language barriers, cognitive impairments, decreased level of consciousness, and sensory disturbances are also at an increased risk of experiencing a medication error (Burke, 2022; Rasool et al., 2020).
A list of high-risk medications that can cause significant patient harm if used in error was published by the Institute for Safe Medication Practices (ISMP). It includes medications with dangerous adverse effects, look-alike/sound-alike (LASA) names (see Table 1), or similar physical appearances but different pharmaceutical properties. The ISMP's List of Confused Drug Names includes LASA drugs that nurses should know to avoid common opportunities for error. Some medications can cause severe harm when misused. These medications should have additional safeguards in place to protect patients from harm. One such safeguard requires two nurses to verify that the correct medication and dose are being administered to a patient (ISMP, 2018; Rodziewicz et al., 2022). Examples of these medications include:
- epinephrine (Adrenalin) intravenous (IV) or intramuscular (IM)
- epoprostenol sodium (Flolan) IV
- vasopressin (Pitressin)
- insulin (all formulations and routes of administration, especially U-500)
- heparin IV
- magnesium sulfate IV
- methotrexate (Rheumotrex) oral for nononcologic use
- nitroprusside sodium (Nipride, Nitropress) IV
- potassium chloride concentrate IV
- potassium phosphates
- promethazine (Phenergan) IV
- oxytocin (Pitocin) IV
- anesthetics (ISMP, 2018; Rodziewicz et al., 2022)
Look-Alike Sound-Alike Medications
Preventing Medication Errors
The prevention of medication errors is the responsibility of the entire healthcare team. The nurse's obligations to prevent medication errors include the following:
- knowing federal, state (nurse practice acts), and local laws and facility policies that govern the prescribing, dispensing, and administration of medications
- performing accurate dosing calculations when indicated
- preparing, administering, and evaluating the patients' responses to medications
- developing and maintaining up‑to‑date knowledge of medications administered commonly in the nurse's practice area, including uses, mechanisms of action, routes of administration, safe dosage range, adverse reactions, side effects, precautions, contraindications, and interactions
- maintaining knowledge of acceptable practice and skill competencies
- determining the accuracy of medication orders
- reporting all medication errors
- safeguarding and storing medications per the manufacturer's instructions (Burchum & Rosenthal, 2019)
Due to the prevalence of prescribing errors in 2014, TJC created a list of unapproved abbreviations. These abbreviations are commonly misinterpreted as something else, resulting in medication errors due to incorrectly interpreting the order and the patient receiving the wrong dose of medication or taking medications at the wrong frequency (TJC, 2022). Examples of abbreviations that should no longer be used are listed in Table 2.
Do Not Use
It can be mistaken for '0', 4, or cc
It can be mistaken for IV or 10
Q.D., QD, q.d., qd
They can be mistaken for each other
Q.O.D., QOD, q.o.d., qod
The period after the Q can be mistaken for an I
every other day
The decimal point can be missed
Do not use a trailing zero
Lack of leading zero
The decimal point can be missed
Make sure that a leading zero is used when the number is less than 1
MSO4 and MgSO4
Mistaken for each other
morphine sulfate or magnesium sulfate
Rights of Medication Administration
Nurses can avoid medication errors using the rights of medication administration. Through this systematic approach, nurses can recognize errors before they reach a patient during medication administration. The Centers for Medicare and Medicaid Services (CMS) have identified five fundamental rights of medication administration. Other sources refer to any number from five to ten rights of medication administration (CMS, 2020; Wisconsin Technical College System, n.d.). The National Council of State Boards of Nursing (NCSBN) test plan notes that the rights of medication administration should be followed when giving medications; however, it does not elaborate any further regarding the number of medication rights (NCSBN, 2018). The ten possible rights of medication administration include:
- right patient: this information should be verified by the patient or patient wristband using two separate patient identifiers, including the patient's name, medical record number, or date of birth; the nurse must verify that this information matches the medication label (if applicable) and medication administration record (MAR)
- right drug: the medication being given must match the order in the MAR; the nurse must also verify that the patient does not have an allergy to the medication
- right dose: the nurse must verify that the dose being given matches the order and is appropriate for the patient
- right route: the nurse must verify that the medication can be administered via the route ordered and that the route ordered is appropriate for the patient (e.g., medications should not be given orally if the patient is unable to take anything by mouth)
- right time or frequency: the nurse must ensure that the prescribed frequency or scheduled time of administration is being followed; this is especially true for medications that must be administered at a specific time (e.g., antibiotics) or for as-needed medications that are not scheduled to ensure they are not given too frequently
- right education: information should be provided to the patient about the medication being administered, including the indication for use and potential adverse effects
- right documentation: proper documentation must be completed to indicate that the medication has been given, preventing a possible duplicate dose
- right history and assessment: the nurse should review the patient's allergies (if not done during the right drug check) and any history of medication reactions; the patient's history should also be checked for possible drug interactions
- right to refuse: after educating the patient about the medication, they have the right to refuse administration; this must be documented and communicated to the prescribing provider
- right evaluation: the nurse should monitor the patient and evaluate them for potential adverse effects (CMS, 2020; Wisconsin Technical College System, n.d.)
The medication administration rights should be performed methodically in a process known as the three checks. The three checks should be performed systematically for the nurse to make the process a habit (Wisconsin Technical College System, n.d.). The rights of medication administration should be completed in the following order:
- first check: as the medication is removed from the dispensing machine or medication cart
- second check: after the medication is removed but before being removed from a multidose container; if required per facility policy, this is when a second nurse performs their safety check
- third check: this happens at the patient's bedside before administering the medication to the patient (Wisconsin Technical College System, n.d.)
In addition to the ten rights and three checks, nurses should ensure that hand-offs are thorough, and that essential information has been communicated to the oncoming or receiving nurse. Bar-code-scanning technology, electronic health records, and computerized prescriber order entry can reduce medication errors when appropriately used (AHRQ, 2019).
Goal 3 of the National Patient Safety Goals addresses medication safety. Three specific medication safety issues were identified: labeling of medications, anticoagulant therapy, and medication reconciliation. How medications are labeled and packaged can lead to medication errors, especially medications that have been removed from their original container and placed into an unlabeled container (i.e., syringe or medication cup). This practice can cause harmful errors leading to death. Medications must be labeled with the medication name, strength, amount of medication if not evident from the container, diluent name if applicable, and the expiration date and time if not being used immediately (TJC, 2021).
Anticoagulation therapy is widely used for both treatment and prophylaxis of venous thromboembolism, for treating atrial fibrillation and pulmonary embolism, and after a mechanical heart valve implant. Anticoagulant use increases a patient's risk of experiencing a medication error or harm from complex dosing, poor monitoring, and lack of compliance with the treatment. Hospitals often follow approved protocols based on evidence-based practice guidelines regarding the use of anticoagulants. These guidelines consider weight-based dosing, age adjustments, renal or liver function adjustments, and drug interactions. The guidelines also outline how the patient should be monitored and how often laboratory values should be checked. Not following these guidelines and hospital policy can lead to medication errors and poor patient outcomes (TLC, 2021).
Medication reconciliation is the process of creating an accurate list of all medications a patient takes to avoid errors. Medication reconciliation is designed to identify and resolve any discrepancies on the medication list. The medication list must include the drug name, dosage, frequency, and route. To ensure the correct medications are administered, the medication list needs to be compared to the provider's orders at admission, at transfer from one hospital unit to another, and at the time of discharge. Potential errors that can occur during medication reconciliation include omitting a medication, duplicating a medication, or recording an incorrect dose or frequency (TJC, 2021).
The concept of professional identity is new to nursing but has been used by other professions—such as veterinary medicine, pharmacy, occupational therapy, and medicine—for over 20 years. In these disciplines, the term professional identity has replaced the term professionalism. The development of this term in relation to nursing began in 2018. In response, the University of Kansas School of Nursing faculty invited nurse leaders across different practice areas to participate in a think tank to define what professional identity means in nursing, along with key elements, competencies, and exemplars. This effort yielded four domains and accompanying definitions, as explained in Table 3. The term professional identity in nursing has already been incorporated into the AACN Essentials (Godfrey, 2022).
Domains of Professional Identity
Values and ethics
Core values and principles that guide a nurse's conduct
Analysis and application of information derived from either nursing or other disciplines
Nurse as leader
Inspiring self and others to transform a vision into reality
A nurse's professional behavior is based on their words, actions, and presence
Embracing and fostering the professional identity of nursing can increase retention rates, promote job satisfaction, boost personal well-being, and improve patient safety and outcomes. Healthcare facilities should promote a culture of professional identity among the nursing staff. Since many medication errors are caused by human error, increasing job satisfaction and personal well-being can negate some of the human factors that lead to medication errors (Owens & Godfrey, 2022).
The domain of values and ethics incorporates the moral principle of nonmaleficence (do no harm). A medication error can cause significant harm to a patient, including death. A nurse who embraces their professional identity makes every effort to ensure that they do not cause harm to a patient due to an error. The domain of knowledge incorporates ongoing professional development and competence. Nurses must be knowledgeable about new medications on the market and their use in practice to fully understand the recommended dose, indications for use, and possible side effects. Furthermore, nurses should actively participate in professional development education delivered by their institution when new policies and procedures are written, or new equipment and medical devices are being used. Being unable to navigate new electronic medical record features or not knowing how to use new medication-related equipment or medical devices can lead to medication errors and patient harm. The domain of nurses as leaders incorporates acting as a mentor and an advocate for staff and patient safety. By acting as leaders, nurses can model proper professional identity and work habits among new employees, further fostering a positive work culture. Acting as a leader also involves advocating for change when a system-process breakdown or unsafe workaround is uncovered to promote patient safety and prevent errors. The last domain is professional comportment, which involves acting professionally in the workplace and promoting a culture of civility, kindness, and support. Promoting a healthy work environment increases communication, support, and education. This type of working environment can decrease human error caused by a lack of education, work-related stress, inadequate staffing, and staff fatigue (Owens & Godfrey, 2022).
Reporting Medication Errors
Medication error-reporting systems (MERs) should be implemented to provide a learning opportunity when medication errors occur. The ISMP has an online medication error reporting system, and each healthcare institution should also have a system for reporting medication errors. Medication errors sometimes result from a system or procedural failure that would not be recognized unless reporting occurs. The barrier to these systems effectively working is the lack of reporting that occurs when a serious or fatal medication error reaches the patient. To foster a culture that openly reports when errors occur, no punitive action should be taken against an individual for reporting an error (ISMP, 2022b; Linden-Lahti et al., 2021).
TJC requires healthcare facilities to report all sentinel events. There are two major frameworks used to analyze medical errors, including medication errors: root cause analysis (RCA) and failure mode and effects analysis (Rodziewicz et al., 2022):
- RCA is used to determine the causative factor(s) that led to the error. RCAs are often used when an event results in patient psychological or physical harm or death. The investigation aims to identify the cause, leading to improvements in the system or processes to prevent repeat errors. The focus of these investigations is not on the individual who uncovered or was responsible for the error. TJC requires healthcare facilities to conduct an RCA for any sentinel event. The results of the RCA must be submitted to TJC for their review. If the institution fails to complete this step, they are placed on an accreditation watch. Being placed on this watch indicates that a sentinel event occurred at the facility, but they have not developed an acceptable action plan to ensure that the same error is not repeated. Reporting by individuals within a healthcare organization should be encouraged to allow for investigations to occur, leading to increased patient safety.
- Failure mode and effects analysis utilizes a proactive approach to identify potential process failures that lead to errors. Failure mode and effects analysis assumes that certain errors will occur no matter what actions a healthcare provider takes. This approach's strategy is to build redundancies as a safety net to catch errors before they occur. For example, a provider enters a medication order, a pharmacist checks the order and dispenses the medication, and then a nurse performs the rights of medication administration and reviews the order and medication for accuracy.
In the past, making a medication error and reporting it did not lead to disciplinary action by the affected facility or legal system. In fact, error reporting and patient safety organizations do not recommend punitive action against an individual reporting an error. This lack of criminal responsibility when making a medication error has changed since the 2022 case of a nurse found criminally negligent due to administering the wrong medication resulting in a patient's death. Although the nurse self-reported the error and was not disciplined by the hospital and initially the state board of nursing, criminal charges were filed. After a hearing, the nurse was found guilty of criminally negligent homicide. This case set a precedent that healthcare providers risk facing criminal repercussions for making an error. This shift can lead to a lack of reporting errors due to fear of prosecution. This can undermine the culture of safety that has been promoted in healthcare facilities especially surrounding the importance of reporting medication errors. Many professional and patient safety organizations have concerns about the transparency of reporting going forward now that there is a risk of criminal prosecution despite a lack of intent to harm (ISMP, 2022a).
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