Running Head: PREVENTION OF COMMON MEDICATION ERRORS IN NURSING 1

Prevention of Common Medication Errors in Nursing

Katherine Tison

University of South Florida, College of Nursing

Nursing roles include but are not limited to medication prescription, calculation, constitution,

checking, administration, patient assessment, documentation, and education (Leufer & Cleary-

Holdforth, 2013). Because nurses have gained so much responsibility and respect in recent years,

is imperative that nurses rise to the occasion and uphold themselves to the highest standards.

Given the amount of time nurses spend administering medications and the number of reported

medication administration errors, it is appropriate to assume that many of these errors are due to

nurses’ mistakes. Though the issue is clearly interdisciplinary, multifaceted, and systematic,

nurses possess a special responsibility as the first-line of defense for patients to be competent in

individual knowledge and performance (Leufer & Cleary-Holdforth, 2013). This paper aims to

examine such errors and discuss possible interventions for avoiding errors.

Miscommunication between healthcare workers can result in many medication errors,

including incorrect dosage. For example, if a day-shift nurse is assigned the task of giving a

medication to control hypertension, but the provider does not appropriately list parameters for

this medication, the day nurse may give an inappropriate dosage. Then, if the day nurse fails to

document properly, the night shift nurse may arrive and administer a similar dose. Thus, errors in

dosage encompass errors in administration, documentation, and communication (Härkänen et al.,

2013). A competent nurse should know what lab values are essential to assess prior to

medication administration, appropriate drug levels for therapeutic effect, and the importance of

proper documentation. Errors at any or all of these steps have the potential to result in not only

poor patient outcomes, but also decreased trust in healthcare (Leufer & Cleary-Holdforth, 2013).

According to Boysen (2013), the essential elements of preventing medication errors include

communicating values and expectations, designing safe systems, managing behavior choices,

creating learning systems, and creating a just and accountable environment. A truly just

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healthcare environment requires nurses themselves to “fully appreciate the complex, dynamic

and multi-faceted phenomenon that is medication management and the ramifications of their

involvement within the process” (Leufer & Cleary-Holdforth, 2013). Nurse competency can best

be achieved with continued nursing education requirements, self-identification of medical errors

with a willingness to receive constructive criticism, and a critical attitude towards the healthcare

system with the goal of creating the safest healing environment possible for hospital patrons

(Stefanacci & Riddle, 2016). Additional aid can be offered to nurses by providers’ fine-tuned

parameters for which drugs are to be administered, as well as quality assurance checks and risk

assessment efforts (Stefanacci & Riddle, 2016). Finally, clear and quick documenting by nurses

and allotment of specific responsibilities to individual nurses can aid in preventing incorrect

dosages and decrease the risk of omission (Härkänen et al., 2013).

I personally feel that mistakes are made when nurses are expected to balance so many things

at once. I think distractions oftentimes interfere with medication administration and assessment

prior to administration. My biggest concern is that I will not do the appropriate assessment prior

to medication administration. I sometimes feel overwhelmed by the number of side-effects and

consequences to individual medications, and I find myself wanting to know the normal for every

lab value for each patient. I think ideally, we would know every normal for each patient before

administering medications. However, this is not possible in reality, and I need to work on

knowing which assessments are the priority when delivering a particular medication so that I do

not miss anything critical.

Though I believe the most successful medication error reduction efforts are likely systematic

approaches, I do think there are strategies individual nurses can take to avoid such problems. For

example, I am trying to study pharmacology and specific drugs prescribed to patients I work with

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in the hospital outside of clinical so that the next time I have a patient on that medication, I am

more comfortable with the side effects and mechanisms. Additionally, I am working on

“knowing what I do not know,” so that I can know when to retrieve help instead of trying to

handle a difficult situation independently.

Medication errors are inevitable, but there are interventions nurses can do to reduce these

errors and create the safest environment possible for patients. Miscommunication between

healthcare workers can lead to many medication errors, and thus efforts to increase the quality of

communication about responsibilities, parameters, and expectations can aid in decreasing such

errors.

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References

Boysen, P. (2013). Just culture: A foundation for balanced accountability and patient safety. The

Ochsner Journal, 13, 400-406. Retrieved from:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/

Härkänen, M., Turunen, H., Saano, S, & Vehviläinen-Julkunen, K. Medication errors: what

hospital reports reveal about staff views. (2013). Nursing Management, 10, 32 – 37.

Retrieved from:

http://ezproxy.lib.usf.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&

db=edsbl&AN=RN328083072&site=eds-live

Leufer, T., & Cleary-Holdforth, J. (2013). Let’s do no harm: Medication errors in nursing: Part 1.

Nurse Education in Practice, 12, 213-216. https://doi.org/10.1016/j.nepr.2013.01.013

Stefanacci, R. & Riddle, A. (2016). Preventing medication errors. Geriatric Nursing, 37, 307-

310. http://dx.doi.org/10.1016/j.gerinurse.2016.06.005