Running head: MEDICATION ERRORS

Medication Errors from a Nursing Perspective

Natasha English
NURS250
Humber College
March 10th, 2016

Running head: MEDICATION ERRORS

2
Introduction

A medication error is defined as any preventable event that may cause or lead to
inappropriate medication use or client harm while the medication is in the control of the health
care professional, client or consumer (CNO, 2008). Giving medication is a serious task that
most nurses do on a daily basis. Patients rely on these medications to properly manage their
illness, and it is up to nurses to ensure that all steps have been taken to ensure proper
administration. Leufer & Cleary-Holdforth (2013) state, Upon registration with the relevant
regulatory bodies, as healthcare professionals we are bestowed with the privilege of looking after
people in our respective care areas . They go on to explain that this includes the duty of
administering medication.
Identify The Problem
Making a mistake when it comes to medication is a serious error. So serious that it can
cause irreparable harm to a patient, or worse, it can cause death. One of the major problems with
medication errors is that when it comes to nursing, caution is not always taken to ensure the
patient is being given the medication as they should be getting it. Medication errors at the
nursing level are largely preventable, but there are many factors which can interfere with proper
administration.
The Data
Before beginning to research, I asked my preceptor what she thought about medication
errors. She mentioned that one of the problems that nurses run into is reading the prescribers
handwriting. Unfortunately, there are many health care providers who write semi-illegibly and
nurses are the ones who have to read, decipher and follow these orders. While it is the nurses job
to clarify any orders which are difficult to read, they may feel as though they read it correctly and

Running head: MEDICATION ERRORS

are clear on what the doctor has written. It leaves room for interpretation. This was something
which was also mentioned throughout the research.
Unfortunately, the research also shows that there are many factors which contribute to
medication errors. Not all of these can be discussed as they are numerous. Allard, Carthey, Cope,
Pitt, & Woodward, S. (2002) give many examples, one of them being the workload of the nurse,
the time of day, and shift work. If the unit is busy nurses are more likely to make an error. This
also happens when nurses work long hours, or theyre doing shift work. Toruner & Uysal (2012)
also mention that long hours is a common factor in making errors.
Another issue that is discussed is that education. Leufer & Cleary-Holdforth (2013) state,
Inadequate or inappropriate education is a factor that can contribute to medication errors.
There may be nurses who choose not to educate themselves on the medications they are giving to
patients. This means that they are unaware of the side effects, required assessments, and how to
manage any negative outcomes. This is also discussed by Allard et al., (2002) and Unver, Tastan,
& Akbayrak, (2012) who note that the experience of the staff plays a role in making mistakes.
Newer nurses are more likely to make mistakes.
Distractions during preparation and administration are another major cause of medication
errors (Toruner & Uysal, 2012). Distractions can come in many forms such as: being tired, loud
environment, and patient interruptions. These cause a lack of focus on properly administering a
medication.
All of the factors that have been brought up all come back to not ensuring that the rights
of medication are followed correctly. The CNO (2008) gives the 8 rights as: right patient, right
medication, right time, right route, right dose, right reason, right frequency, and right site.

Running head: MEDICATION ERRORS

Regardless of the situation, its clear that these need to be followed carefully and nurses need to
ensure they are doing everything they can to see that all the rights are followed in every situation.
The Alternatives
I believe there are many different strategies to eliminate med errors. I also believe that it
may require a mix of different strategies to reduce the risk as much as possible. The most
obvious solution to reducing medication errors to ensure that the Rights of Medication are
followed diligently each and every time administration occurs. However, I wont be focusing on
that as this should be happening currently, and is the most important key to reducing errors. The
focus will be on two alternatives that are not currently standard.
One alternative is to have doctors use technology to write orders. There are various
methods by which this can happen. They can bring a computer with them into each visit with a
patient, and immediately enter the orders into the patient record, or into a program to print them
out. I have personally witnessed a Doctor who had a program on an tablet which was connected
wirelessly to a portable printer. When he entered the information into the program, he could then
print it out right away. This eliminates the chance that nurses will assume they understand the
order and have deciphered it correctly. It will ensure that anyone reading the order will clearly
see the same information, and the information as it was intended to be written.
A second alternative is to alter the practice of nurses before giving medications. This
comes in two parts. The first is to have a dedicated area for medication. This room is one which
cannot be accessed by anyone but the health care team. The door closes to provide a quiet
environment free from distractions. The second part to this is that once nurses calculate dosage,
get the correct medication and dose, they then take it to another nurse to check and sign off. That
second nurse must look at the order and calculate without looking at the first nurses work. This

Running head: MEDICATION ERRORS

minimizes errors because it means that two different people are using their knowledge and skill
to come to the same conclusion. It is a way to catch any errors that the first nurse makes. This is
the current practice on the unit in which I am doing my pre-graduate experience.
I believe the second alternative would be far easier to implement as integrating technology for
every doctor is something that could be very costly, and every hospital may not want to take on
this financial responsibility.
Implementation
In order to implement the second alternative, there would need to be a person or team on
each unit to lead the planning and education of the staff. The team would have to pick an area,
for example, the corner of the clean supply room, and transform it into a small medication area.
It should be complete with drug dictionaries, calculators, paper and pens, medication
administration records and any other relevant supplies. If possible, designate an entire room for
this. However, some hospitals may have less space and this may not be a possibility, so an area
that is off limits to patients would suffice. The second step is to create a process document which
outlines the new process of having two nurses check and sign off on each medication. The last
step is to educate the team on the changes. This could be done by team meetings, huddles, emails, and distribution of the new process document.
Evaluating Success
Evaluating the success of these changes is only evident in the number of errors being
made. Since medication errors are to be reported, there is data available to look at. Therefore, it
would best be evaluated by looking at the data to see if medication errors have decreased in the
areas which have implemented the changes. It also could be evaluated by anonymous surveys.
This would be distributed to units where changes have been made, and also to units where they

Running head: MEDICATION ERRORS

have not. Questions would be asked on medication errors and the results compared between the
two groups.
Conclusion
As new nurses, we are going to have to really work hard to ensure medication errors are
not being made. We are going to be inexperienced and getting used to a new role, with new
working hours and new environments. We are going to have many factors working against us.
Its up to us to take control and use our newly acquired knowledge, skill, and judgement and
remember that administer medication is a serious task.

Running head: MEDICATION ERRORS

7
References

Allard, J., Carthey, J., Cope, J., Pitt, M., & Woodward, S. (2002). MEDICATION ERRORS:
CAUSES, PREVENTION AND REDUCTION. British Journal Of Haematology, 116(2),
255-265.
College of Nurses of Ontario (2014). Medication. Practice Standard. 1-17.
Leufer, T., & Cleary-Holdforth, J. (2013). Let's do no harm: Medication errors in nursing: Part 1.
Nurse Education in Practice, 13(3), 213.
Toruner, E. K., & Uysal, G. (2012). Causes, reporting, and prevention of medication errors from
a pediatric nurse perspective. Australian Journal of Advanced Nursing (Online), 29(4),
28-35.
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly
graduated and experienced nurses. International Journal Of Nursing Practice, 18(4),
317-324.