Medication

Errors
Nicole Rosebrock &
Jennifer Edson

Introduction
In the United States medication errors
injure 1.3 million people each year. In
addition to injuries, a death occurs each
day from these preventable errors. Nurses
are on the frontlines, administering
medications. Nurses are the last line of
defense protecting patients against
medication errors.

Objectives
Define

what medication errors are.

Identify

how medication errors occur.

Identify

opportunities to reduce

medication errors in the hospital setting

Assessment of the Health Care

Environment
Policies
The Federal Food, Drug, and Cosmetic
Act
Standardized labeling
Requires drugs are effective and safe
in their uses

Safety
Reduce risk of harm to patients

Assessment of the Health Care

Environment
Resources
Electronic medication administration
system- reduce prescribing errors
Bar code scanner- Right patient, right
medication, right time and right dose
Pharmacy
Computerized physician-order entry

Assessment of the Health Care

Environment
Nursing Practice
Front

lines
Administer medications to patients
Follow 5 Rights
Utilize available resources
Limit distractions

Definition of Medicine Error

A medication error is "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 (U.S. Food and Drug
Administration, 2009).
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 (U.S. Food
and Drug Administration,
2009)."

Occurrences
1983-1993

Phillips, D., et el, (1998, p. 643)

Root Cause Analysis for Double Coverage of Insulin

Dolansky, M, et el, 2013, p. 104)

?
Who

Wh
a t?

ing s
t
bu ror
i
r
nt n Er
o
s C atio
r
to dic
c
Fa Me
Wh to
ere
?

o
w

Wa
fo tch
r
er
ro
rs!
When?

Google images, 2015

Time Out for Medication Dispersing!

FACTS
44,000-98,000 patients die in the united
states related to medical errors.
25% of patients left with disabilities after
admission are due to medical error.
19% of errors are medication errors.
Thats 6.5 events per 100 hospital
administration
Medication errors cost $2 billion dollars a
year in health care expenses, nationally.

(Pham, J., et el, 2011, p. 485)

Conclusion for Safe Medication

Delivery

Recommendations

FDA Regulations

The use of PDAs for dispersing medications.

Smart IV machines with guardrail drugs
listed
Physicians Order Entry.
Pharmacy to verify order
Nurse to verify order
Patients 5 rights
Medication correct, on time charting in one
place (MAR)
Time out while dispersing medication, avoid
distractions.
Double check/cross reference of any
possible interactions
Call the pharmacist and/or the ordering
physician if you have any questions or
doubt.

Dont feel like this. Follow

The rules, and dont be
distracted
Google image, 2015

References
Dolansky, M., Druschel, K., Helba, M., Courtney, K. (March/April, 2013). Nursing student medication errors: A case study using
root cause analysis. Journal of Professional Nursing. 29(2)., 102-108. doi: 10.1016/j.profnurs.2012.12.010
Hester, M. (2010). Best practices in safety: minimizing disruptions during medication administration. Texas Board of Nursing
Bulletin, 40(1) 5-6. Retrieved
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Pham, J.C., Story, J., Hicks, R., Shore, A., Morlock, L., Cheung, D., Kelen, G., Pronovost, P. (2011). National study on the frequency,
types, causes, and consequences of voluntarily reported emergency department medication errors. The Journal of Emergency
Medicine. 40(5), pp. 485-492. doi: 10.1016/j.jemermed.2008.02.059
Phillips, D., Christenfeld, N., Glynn, L. (February 28, 1998). Increase in US medication-error deaths between 1983-1993. The
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http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&sid=a77255ace7b53c9d27882f6b965a1b96&rgn=div5&view=text&node=21:7.0.1.1
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