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Medication Errors and Student Nursing
Emery Horvath
University of South Florida
MEDICATION ERRORS 2
Medication Errors and Student Nursing
Medication errors are an unfortunate common occurrence for patients during their
hospitalization. Many factors including imperfect systems, human mistakes, and bypassed
protocols all contribute to these errors. This paper will examine common medication errors
committed by nurses, how these errors impact patients and their families, and how these mistakes
may be avoided in the future. Additionally, this paper will reflect on the impact of medication
errors on student nurses and propose proactive steps for student nurses to take in preventing their
own medication errors.
Wrong Medication Selection Errors
Despite advancements in automated dispensing cabinets it is still common that a nurse
will need to specifically search for a medication. When this occurs, many systems require only
the first three letters of the drug, unfortunately many drugs share the same prefixes ultimately
leading to administering the wrong medication. For example, a nurse intending to pull Briviact
may accidentally pull Brilinta instead (2020). There are a multitude of drugs that have this
similarity in naming leading to mix-ups with potentially fatal consequences.
Impact on Patients and Family
Mistaking medications is especially critical when the patient requires medications to
stabilize body processes and restore homeostasis. For example, the drug amantadine is an
antiviral often used to treat motor symptoms of Parkinson’s disease, the drug amiodarone is an
antiarrhythmic used for cardiac patients with irregular rhythms. Either way this swap goes the
result is a patient being treated for something unnecessary and missing out on the treatment they
need to maintain their health. Not only can this error disrupt the patient’s health and path to
recovery there are also a multitude of implications for the family. This medication error can
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disrupt both the emotional wellbeing of family members, and logistically disrupt a caregiver’s
routine with the patient.
Nursing Intervention
Mistakenly pulling the wrong medication is an entirely avoidable error. As a nurse it is
essential to perform at least three checks of a medication prior to giving it to the patient: once
when pulling from the automated dispensing cabinet, once when preparing the medication, and
again when opening and giving to the patient. When a nurse performs these checks routinely,
they have three opportunities to recognize that they have pulled the incorrect medication.
Additionally, the Institute for Safe Medication Practices recommends that nurses type the first
five letters of a medication name rather than the first three to decrease the chances of selecting
the incorrect medication (2020). It is essential that nurses prioritize these safety checks
throughout their day to protect patients from medication errors.
Misheard Verbal Medication Orders
Nurses are often responsible for receiving verbal orders from other health care providers
and then entering those orders into the computer. These interactions are often brief and during an
emergency or over the phone. This increases the likelihood of a nurse mishearing the medication
ordered by the other provider. Similar to drugs with almost identical spellings there are numerous
drugs that sound the same as well. Additionally, it is possible to mishear a prefix that changes the
drug order completely. For example, in an emergency or during a procedure the order of
antithrombin could be misheard as thrombin which would yield the opposite of the desired effect.
Impact on Patients and Family
Misheard medication orders commonly happen at times when efficiency and accuracy are
exceedingly important, such as during an emergency or surgery. In these high-pressure situations,
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the stakes are often higher and thus the consequences for a medication error are often more
severe for the patient, potentially leading to life-altering/threatening consequences. Additionally,
family members would likely feel especially powerless in these high stakes situations where their
ability to advocate for their loved one is limited.
Nursing Intervention
Preventing verbal misunderstandings is entirely possible when the time is taken to
readback an order prior to administering a medication. This includes reading out the drug name,
route, frequency, and dose. This quick intervention gives the nurse and the provider a moment to
doublecheck themselves and each other to ensure that the patient is receiving the appropriate
medication. It is also essential that nurses have a comprehensive understanding of pharmacology.
Studies have shown that skilled experienced nurses with pharmacological knowledge of a
medication, its uses and potential complications can minimize medication errors (Salar et al.,
2020). Nurses who understand what a medication does and why it would be indicated are
empowered to think critically about an order given and identify if an order may have been
misheard or does not make sense.
Unsafe Overrides of Automated Dispensing Cabinets
The use of automated dispensing cabinets is commonplace in most if not all healthcare
facilities. One vulnerability of these systems is the inappropriate use of overrides leading to
potential medication errors. An additional error with unsafe overrides occurs when nurses
withdraw a medication they anticipate orders for, this is especially common on specialty units
such as labor and delivery. Finally, the removal of medication from a non-profiled automated
dispensing cabinet which allows the provider access to all the medications in the cabinet can also
lead to medication errors. There are some situations when these overrides are necessary this also
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means that a pharmacist may never review the medication order and increases the chances of
administering the wrong medications (2019).
Impact on Patients and Family
The impact of medication errors due to unsafe overrides is twofold. First as discussed
previously administering the incorrect medication to a patient jeopardizes the patient’s health and
has all the aforementioned consequences for the patient and their family. Secondly, frequent
unsafe overrides have the potential to jeopardize systems that allow for overrides when they are
medically necessary such as in emergency situations. There are times where an override is
medically necessary and thus making overrides impossible in these situations also jeopardizes
patient’s health. Thus, having systems in place that protect against unnecessary overrides while
allowing for medically necessary ones is essential to the health of a patient and positive
outcomes for a patient’s family.
Nursing Intervention
Nurses must be clear on facility policy when it comes to overriding an automated
dispensing cabinet. It is not possible to completely eliminate the need for overrides as patient’s
conditions can change rapidly however a comprehensive system paired with a nurse using the
system responsibly as it is designed can minimize the potential harms of overrides. Additionally,
an important aspect to any override is a rationale, this adds a step so that nurses think through the
medication they are administering and more importantly why they are giving it (2019).
Integrating critical thinking with performing tasks protects nurses from preventable medication
errors caused by complacency.
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Impact on Students
Personally, this paper has highlighted two things about medication errors: they are
preventable, and preventing them requires active thinking about patient needs and care. The
medication errors that make me the most nervous are ones that occur due to complacency,
whether it relates to pulling a lookalike medication or not reading back a verbal order. To prevent
these kinds of errors I will create systems for myself to keep me alert and accountable to the
patient and their medication. Currently in my clinicals prior to medication administration I
ensure that I can explain the medication, what it does, how much they are getting, why they are
getting, and what potential reactions I should be watching out for. Maintaining this practice when
I am a registered nurse will be essential in ensuring I provide safe care.
Conclusion
Reflecting on medication errors has highlighted how preventable most if not all
medication errors are. Medication errors are a very real problem in nursing, and it is important to
understand that I am more than capable of committing a medication error myself, but I am also
more than capable of preventing them. This paper also helped me to reflect on the importance of
adherence to safety precautions even if they are not the norm on certain units, and as patient
advocates it is important to advocate for safety adherence throughout the unit.
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References
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Teaching strategies that increase nursing students' awareness of medication errors and their
prevention. Nurse Education Today, 52, 7–9. https://doi.org/10.1016/j.nedt.2017.02.004
Over-the-Top Risky: Overuse of ADC Overrides, Removal of Drugs without an Order, and Use
of Non-Profiled Cabinets. Institute For Safe Medication Practices. (2019, October 24).
https://ismp.org/resources/over-top-risky-overuse-adc-overrides-removal-drugs-without-
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edication%20selection.
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qualitative study. International Journal of Africa Nursing Sciences, 13, 100235.
https://doi.org/10.1016/j.ijans.2020.100235
Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards.
Institute For Safe Medication Practices. (2020, January 16).
https://www.ismp.org/resources/start-new-year-right-preventing-these-top-10-medication-
errors-and-hazards.
