Running head: MEDICATION SAFE PRACTICE PAPER

Medication Safe Practice Paper

Nina Wilczynski
The University of South Florida

MEDICATION SAFE PRACTICE PAPER

According to the National Coordinating Council for Medication Error Reporting and
Prevention (NCCMERP) (2015), 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". Whenever a medication error causes
harm to an individuals health, it is known as an adverse drug event (Mayo Clinic 2015).
Medication errors are one of the most common medical errors. Each year they harm over 1.5
million people in the United States and convey a cost of billions of dollars for the treatment of
drug related injuries (Stencel C., Dobbins C., 2006). These errors have a grave injurious nature
in relation to a persons health, well being and quality of life, as well as a large fiscal burden.
Recognition of leading causes of medication errors, as well as knowledge of tactics one can to
use to thwart them, is important in their prevention.
In one study, a meta-analysis was conducted of empirical literature related to the causes
of medication errors. The literature review spanned four major databases, including PubMed,
CINAHL, Science Direct and Synergy, from the years 1988 to 2007. The results showed that
causes for medication errors are both individual and systems related (Brandy A. M., Malone A.
M., Fleming S., 2009). Reasons for errors caused by an individual include distractions during
medication administration, excessive workloads and an inadequate knowledge of medications.
Following hospital procedures is a major component to preventing distractions during
medication administration. Many hospitals have a quiet box, where a box is taped out on the
ground around the medication storage system. When a nurse is inside that box, no one is
allowed to speak to or distract that nurse. Even when such rules are not set though hospital
policies, nurses must remember to not allow distractions during medication administration. If
asked to help another nurse, one must say no and focus on performing the medication

MEDICATION SAFE PRACTICE PAPER

administration. Also, timing medication administration is helpful in the prevention of errors

(Manias E., Aitken R., Dunning T., 2005). Setting a time where one is to give medicine helps a
nurse to focus solely on that purpose during the set hour and aids in timely administration of
medication.
Timing of medication administration and actively focusing on that task to prevent
distraction also is helpful to a nurse with a large workload. An increased workload puts more
cognitive pressure on a nurse, forcing them to remember more tasks they need to do to provide
patient care. Mentally keeping track of all that information becomes less effective as workload
increases. Having an organized system to remember tasks, such as a written list of
responsibilities needing to be carried out, helps to prevent a nurse from forgetting these tasks.
Verifying patient identification though a patients verbal response, their patient identification
wristband and their chart before administering medication is also an important tactic to prevent
medication errors, especially in times of increased workload (Manias E., Aitken R., Dunning
T., 2005). Finally, double checking the name, dose and route of a medication before
administration further helps to eliminate medication errors (Manias E., Aitken R., Dunning T.,
2005). Labeling syringes with the name and dosage of medicine before leaving the medication
room aids the nurse to double check the medicine before its administration in a patients room.
These strategies are important even when labor is not as intensive. However, they prove vital
and effective during times of increased workload.
An inadequate knowledge of medications is also a large cause for medication errors.
Continuous education for a nurse is imperative in learning and remembering medication related
information. Nurses may need to review and even re-learn pharmacological information related
to drugs they do not commonly give. Two tools that aid in medication error prevention include

MEDICATION SAFE PRACTICE PAPER

participation in hospital provided pharmacology classes and continued self study of

pharmacology. To prevent medication errors, nurses should practice never administering
medicine without knowing what that drug is used for, its contraindications, side effects and
other pertinent information. A nurse should always know what labs and side effects to monitor
after medication administration. Also, a nurse should gain and maintain mathematical
competency in relation to drug administration (Brandy A. M., Malone A. M., Fleming S.,
2009). Basic mathematics is often used to know the right dosage needed to give a patient.
Thus, three main reasons for an individual nurse to cause a medication error include
distraction from medication administration, excessive workloads and an inadequate knowledge
of medications. There are many more reasons that medication errors have occurred. Other
reasons include systems errors. Systems errors include improper or untimely medication
reconciliation with a patients doctor, the types of drug distribution systems and the quality of a
prescription (Brandy A. M., Malone A. M., Fleming S., 2009). Nursing managers and hospital
administrations should be continually assessing and evaluating systems errors, as well as
searching for ways to stop them. Nursing managers should also promote the writing of incident
reports. The health and financial impacts of medication errors are so large that their prevention
should be a main focus for nurses in providing safe and ethical care for patients. Reporting
medication errors are necessary to assess their cause, implement prevention strategies and
promote quality patient care. The use of other basic prevention strategies, such as the ones
mentioned in the above paragraphs, is also vital in preventing medication errors.

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References

Brady, A., Malone, A., & Fleming, S. (2009, August 11). A Literature Review Of The Individual
And Systems Factors That Contribute To Medication Errors In Nursing Practice. Journal
of Nursing Management, 17(6), 679-697.
http://www.ncbi.nlm.nih.gov/pubmed/19694912
Manias, E., Aitken, R., & Dunning, T. (2005, August 4). How Graduate Nurses Use Protocols To
Manage Patients Medications. Journal of Clinical Nursing, 14(8), 935-944.
http://www.ncbi.nlm.nih.gov/pubmed/16102145
Mayo Clinic (2014, September 23). Medication errors: Cut your risk with these tips. Retrieved
from http://www.mayoclinic.org/healthy-living/consumer-health/in-depth/medicationerrors/art-20048035?pg=1
National Coordinating Council for Medication Error Reporting and Prevention (2015). What is a
Medication Error? Retrieved from http://www.nccmerp.org/about-medication-errors
Stencel, C., & Dobbins, C. (2006, July 20). Preventing Medication Errors: Quality Chasm
Series. Retrieved from
http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623