What is the nurse’s priority action to protect a patient from medication error?

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​by Frank Federico, RPh, Executive Director, Institute for Healthcare Improvement

One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time. When a medication error does occur during the administration of a medication, we are quick to blame the nurse and accuse her/him of not completing the five rights. The five rights should be accepted as a goal of the medication process not the “be all and end all” of medication safety. 

Judy Smetzer, Vice President of the Institute for Safe Medication Practices (ISMP), writes, “They are merely broadly stated goals, or desired outcomes, of safe medication practices that offer no procedural guidance on how to achieve these goals. Thus, simply holding healthcare practitioners accountable for giving the right drug to the right patient in the right dose by the right route at the right time fails miserably to ensure medication safety. Adding a sixth, seventh, or eighth right (e.g., right reason, right drug formulation, right line attachment) is not the answer, either.” [The five rights: A destination without a map. ISMP Medication Safety Alert. January 25, 2007;12(2).]

The five rights focus on individual performance and not on human factors and system defects that may make completing the tasks difficult or impossible.

There are a number of factors that may interfere with a nurse’s ability to complete these functions.

Ms. Smetzer continues, “Thus, the healthcare practitioners’ duty is not so much to achieve the five rights, but to follow the procedural rules designed by the organization to produce these outcomes. And if the procedural rules cannot be followed because of system issues, healthcare practitioners also have a duty to report the problem so it can be remedied.”

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A critical care nurse tries to catch up with her morning medications after her patient’s condition changes and he requires several procedures. He is intubated, so she decides to crush the pills and instill them into his nasogastric (NG) tube. In her haste to give the already-late medications, she fails to notice the “Do not crush” warning on the electronic medication administration record. She crushes an extended-release calcium channel blocker and administers it through the NG tube. An hour later, the patient’s heart rate slows to asystole, and he dies…

A patient returns from surgery, anxious and in pain, with several I.V. lines and an intracranial pressure (ICP) monitor in place. The I.V. tubing used in the operating room differs from the tubing used in the intensive care unit (ICU). In her haste, the ICU nurse prepares to inject morphine into the patient’s ICP drain, which she has mistaken for the central line. She stops just in time when she realizes she’s about to make a serious mistake…

A physician writes an order for primidone (Mysoline) for a 12-year old boy with a seizure disorder. Misreading the physician’s handwriting, the pharmacist mistakenly fills the order with prednisone. For 4 months, the boy receives prednisone along with his seizure medications, causing steroid-induced diabetes. The diabetes goes unrecognized, and he dies from diabetic ketoacidosis…
Medication errors like these can happen in any healthcare setting. According to the landmark 2006 report “Preventing Medication Errors” from the Institute of Medicine, these errors injure 1.5 million Americans each year and cost $3.5 billion in lost productivity, wages, and additional medical expenses. (See Sobering statistics by clicking the PDF icon above.)

Medication administration is a complex multistep process that encompasses prescribing, transcribing, dispensing, and administering drugs and monitoring patient response. An error can happen at any step. Although many errors arise at the prescribing stage, some are intercepted by pharmacists, nurses, or other staff.

Administration errors account for 26% to 32% of total medication errors—and nurses administer most medications. Unfortunately, most administration errors aren’t intercepted. Recent technological advances have focused on reducing errors during administration.

Ten key elements of medication use

Many factors can lead to medication errors. The Institute for Safe Medication Practices (ISMP) has identified 10 key elements with the greatest influence on medication use, noting that weaknesses in these can lead to medication errors. They are:

• patient information
• drug information
• adequate communication
• drug packaging, labeling, and nomenclature
• medication storage, stock, standardization, and distribution
• drug device acquisition, use, and monitoring
• environmental factors
• staff education and competency
• patient education
• quality processes and risk management.

Patient information

Accurate demographic information (the “right patient”) is the first of the “five rights” of medication administration. Required patient information includes name, age, birth date, weight, allergies, diagnosis, current lab results, and vital signs.

Barcode scanning of the patient’s armband to confirm identity can reduce medication errors related to patient information. But initially, barcode technology increases medication administration times, which may lead nursing staff to use potentially dangerous “workarounds” that bypass this safety system. Also, the barcode method isn’t fail proof; the patient’s armband may be missing or may fail to scan, or the scanner’s battery may fail.

Drug information

Accurate and current drug information must be readily available to all caregivers. This information can come from protocols, text references, order sets, computerized drug information systems, medication administration records, and patient profiles.

Adequate communication

Many medication errors stem from miscommunication among physicians, pharmacists, and nurses. Communication barriers should be eliminated and drug information should always be verified. One way to promote effective communication among team members is to use the “SBAR” method (situation, background, assessment, and recommendations).

Poor communication accounts for more than 60% of the root causes of sentinel events reported to the Joint Commission (JC). In a 2001 case, a patient died after labetalol, hydrala­zine, and extended-release nifedipine were crushed and given by NG tube. (Crushing extended-release medications allows immediate absorption of the entire dosage.) As a result, the patient experienced profound bradycardia and hypotension leading to cardiac arrest. Although she was successfully resuscitated, she received the drugs the same way the next day. Clinicians had failed to communicate to other team members that her initial cardiac arrest had occurred shortly after she’d received the medications improperly.

Drug packaging, labeling, and nomenclature

Healthcare organizations should ensure that all medications are provided in clearly labeled unit-dose packages for institutional use. Packaging for many drugs looks similar. A tragic case stemming from such similarity occurred with heparin (one of the drugs on the JC’s “high-alert” list, meaning it has a high potential for causing patient harm). A few years ago, several pediatric patients received massive heparin overdoses due to misleading packaging and labeling; three infants died. As a result, the Food and Drug Administration and Baxter Healthcare (the heparin manufacturer) issued a letter via the MedWatch program alerting clinicians to the danger posed by similarly packaged drugs. Baxter has since enhanced the labels on heparin and some other high-alert drugs; it now uses a 20% larger font size, tear-off cautionary labels, and different colors to distinguish differing drug dosages.

Look-alike or sound-alike medications—products that can be confused because their names look alike or sound alike—also are a source of errors. From 2003 to 2006, 25,530 such errors were reported to the Medication Errors Reporting Program (operated jointly by the U.S. Pharmacopeia and ISMP) and MEDMARX (an adverse drug event database). The JC requires healthcare institutions to identify look-alike and sound-alike drugs each year and have a process in place to help ensure related errors don’t occur.

Medication storage, stock, standardization, and distribution

Also, hospitals can use commercially available products to decrease the need for I.V. compounding medications and I.V. admixing. Use of preprinted order sets and standardized formularies can reduce errors, too. The Institute for Healthcare Improvement recommends standardized order sets and pre­printed protocols for 75% of the drugs healthcare facilities use. These orders and protocols help clinicians promptly select correct dosing regimens, routes, and parameters while eliminating ambiguous abbreviations and the risk of misreading a prescriber’s handwriting.

However, errors can occur even when automated dispensing cabinets are stocked by technicians. In a recent error reported to the ISMP, a technician filled an automated dispensing cabinet with the wrong concentration of a premixed potassium chloride I.V. solution.

Drug device acquisition, use,and monitoring

Improper acquisition, use, and monitoring of drug delivery devices may lead to medication errors. Some delivery systems have inherent flaws that increase the error risk. For example, at one time, I.V. medication tubing continued to flow or infuse when removed from the pump. Thus, patients could receive boluses of medications or I.V. solutions, which sometimes had deleterious outcomes. During the admission process, for instance, a patient receiving nitroprusside could receive a large infusion of this drug when the I.V. tubing was removed from the pump and the patient was transferred from one bed to another. This design flaw has since been resolved. In addition, syringes for administering oral medications should not be compatible with I.V. tubing.

Environmental factors

Environmental factors that can promote medication errors include inadequate lighting, cluttered work environments, increased patient acuity, distractions during drug preparation or administration, and caregiver fatigue. (See The fatigue factor by clicking on the PDF icon above.)

Distractions and interruptions can disrupt the clinician’s focus, leading to serious mistakes. To reduce interruptions, Sentara Leigh Hospital in Norfolk, Virginia has instituted a “no interruption” zone around the automated medication dispensing machines; coworkers know not to interrupt a nurse who’s obtaining medication from the machine.

Heavier workloads also are associated with medication errors. The nursing shortage has increased workloads by increasing the number of patients for which a nurse is responsible. Also, nurses perform many tasks that take them away from the patient’s bedside, such as answering the telephone, cleaning patients’ rooms, and delivering meal trays. Absence of nurses from the bedside is directly linked to compromised patient care.

Staff education and competency

Continuing education of the nursing staff can help reduce medication errors. Medications that are new to the facility should receive high teaching priority. Staff should receive updates on both internal and external medication errors, as an error that has occurred at one facility is likely to occur at another. (The heparin overdoses described earlier happened at multiple institutions.)

As medication-related policies, procedures, and protocols are updated, this information should be made readily available to staff members. Also, nurses can attend pharmacy grand rounds. Some facilities now use nursing grand rounds as a way to keep staff members competent.

Patient education

Caregivers should teach patients the name of each medication they’re taking, how to take it, the dosage, potential adverse effects and interactions, what it looks like, and what it’s being used to treat.

Quality processes and risk management

A final strategy for reducing medication errors is to establish adequate quality processes and risk-management strategies. Every facility should have a culture of safety that encourages discussion of medication errors and near-misses (errors that don’t reach a patient) in a nonpunitive fashion. Only then can effective systems-based solutions be identified and used.

Simple redundancies, such as using an independent double-check system when giving high-alert drugs, can catch and correct errors before they reach patients. According to the Institute of Medicine, organizations with a strong culture of safety are those that encourage all employees to stay vigilant for unusual events or processes.

Consequences for the nurse

For a nurse who makes a medication error, consequences may include disciplinary action by the state board of nursing, job dismissal, mental anguish, and possible civil or criminal charges. In one study of fatal medication errors made by healthcare providers, the providers reported they felt immobilized, nervous, fearful, guilty, and anxious. Many experienced insomnia and loss of self-confidence.

Avoiding medication errors

How can you safeguard your practice from medication errors? For starters, be conscientious about performing the “five rights” of medication administration every time—right patient (using two identifiers), right drug, right dosage, right time, and right route. Some experts have expanded this list to include:

• right reason for the drug
• right documentation
• right to refuse medication
• right evaluation and monitoring

Be sure to use the safety resources available at your facility. Don’t use workarounds to bypass safety systems. In a 2008 study, one-third of nurses reported they sometimes bypass safety systems. Nurses working in critical care and pediatrics were more likely to do this; yet medication errors in these settings can be particularly devastating. Where nurses routinely bypass safety systems and create work­arounds, the employer must conduct a root-cause analysis to identify the reason for the workaround, and take action to correct the situation and prevent recurrences.

Additional steps you can take to promote safe medication use include:

• reading back and verifying medication orders given verbally or over the phone. (See Reading back medication orders by clicking on the PDF icon above.)
• asking a colleague to double-check your medications when giving high-alert drugs
• using an oral syringe to administer oral or NG medications
• assessing patients for drug allergies before giving new medications
• becoming familiar with your facility’s “do not use” list of abbreviations. In 2004, the JC published a list of abbreviations that shouldn’t be used because they can contribute to medication errors. For instance, in one documented case, a “naked” decimal point (one without a leading zero) led to a fatal tenfold overdose of morphine in a 9-month-old infant. The dosage was written as “.5 mg” and interpreted as “5 mg.”

Eliminating medication errors

Avoiding medication errors requires vigilance and the use of appropriate technology to help ensure proper procedures are followed. Computerized physician order entry reduces errors by identifying and alerting physicians to patient allergies or drug interactions, eliminating poorly handwritten prescriptions, and giving decision support regarding standardized dosing regimens.

The Leapfrog Group (whose mission is to trigger giant leaps forward in healthcare safety, quality, and affordability) supports computerized physician order entry as a way to reduce medication errors. Use of computerized physician order entry and barcodes may reduce errors by up to 50%.

Yet computerization can’t prevent or catch all errors. In one near-miss incident, an I.V. bag of a standardized diltiazem (Cardizem) solution (125 mg in 125 mL normal saline solution) was inadvertently labeled as an insulin drip, even though it had scanned correctly (the barcode had been applied by the pharmacy). Fortunately, an alert ICU nurse realized the bag she had in her hand was a premixed solution and not a pharmacy admixture. When she turned it over, she could see the manufacturer’s label.

Be sure to use the safety practices already in place in your facility. Eliminate distractions while preparing and administering medications. Learn as much as you can about the medications you administer and ways to avoid mistakes. (See Websites that can help you avoid medication errors by clicking on the PDF icon above.) Finally, be aware of the role fatigue can play in medication errors.

Selected references

Consumers Union. To Err is Human—To Delay is Deadly. May 2009. www.safepatientproject.org. Accessed February 1, 2010.

Institute for Safe Medication Practices. ISMP Medication Safety Alert! Nurse Advise-ERR [Newsletter]. www.ismp.org. Accessed February 1, 2010.

Hicks RW, Becker SC, Cousins DD. MEDMARX data report. A report on the relationship of drug names and medication errors in response to the Institute of Medicine’s call for action. Rockville, MD: Center for the Advancement of Patient Safety, U.S. Pharmacopeia; 2008.

Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

Koppel R, Wetterneck T, Telles J, Karsh B. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15(4):408-423.

Rogers A, Hwang W, Scott L, Aiken L, Dinges D. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202-212.

Sakowski J, Newman J, Dozier K. Severity of medication administration errors detected by a bar-code medication administration system. Am J Health Syst Pharm. 2008;65(17):1661-1666.

Visit www.AmericanNurseToday.com/archives for a complete list of selected references.

Pamela Anderson is an adult nurse practitioner nurse at Clarian Health in Indianapolis, Indiana; a resource pool float nurse at Ball Memorial Hospital in Muncie, Indiana; and a p.r.n. ICU nurse at Tipton Hospital in Tipton, Indiana. Terri Townsend works in the cardiovascular ICU and the cardiac telemetry unit at Ball Memorial Hospital and holds an adjunct clinical faculty position at Ball State University School of Nursing in Muncie. The planners and authors of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.

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