MEDICATION ERRORS AND THE IMPACT ON PATIENTS 1

Medication Errors in the Clinical Setting and Their Impact on Patient Outcomes

Gracie Moravecky

College of Nursing, University of South Florida

NUR3225L: Complex Health 1

Dr. Marc Rosales

April 8, 2023
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Most people, when hospitalized or receiving medical treatment put immense trust in their

healthcare team. They trust that they will be diagnosed accurately, treated properly, and

medicated safely. After all, this is what health care providers and workers spend so much time in

school learning how to do. However, when medication errors occur, they have the potential to

destroy so much more than just a patient’s trust. Not only might they cause substantial harm to

the patient, but the worker involved may lose their career depending on the severity of the error,

in a world that is already desperately short on health care workers. Some of the most common

medication errors include giving the wrong patient a medication, giving the wrong dose of a

medication, and/or giving the wrong medication altogether. These medication errors can happen

for a variety of reasons including negligence on the part of the nurse, medication calculation

errors, and factors such as excessive overtime hours and an understaffed unit that leads to

exhaustion of the healthcare team.

One of the most common medication errors is administering a medication to the wrong

patient. This is a common error that can occur by not verifying the patient’s identity with at least

two unique identifiers or simply mistaking the patient room. This is a crucial part of the five

rights of medication administration which include right patient, right drug, right dose, right time,

and right documentation. Administering a medication to the wrong patient can result in severe

adverse and potentially fatal reactions, especially if a particular medication is not indicated for

that patient. Another common medication error is giving the wrong dose of a medication. This

can happen as a result of an incorrect dosage calculation, illegible order, or simple negligence by

not double checking the amount drawn up or dispensed. Again, an error such as this can have

dire effects on a patient including overdose and death. The third most common medication error

is giving the wrong medication to a patient. This can result from not completing the three
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medication checks; one after pulling the med, one after preparing the med, and one before

administering the med. An error such as this, much like administering a medication to the wrong

patient can result in hypersensitivity responses and death.

Of course, there are other factors at play other than negligence on the part of the nurse.

According to research from Alrabadi et al., “the main causes contributing to medication errors

are illegible handwriting, mental and physical health, interruption and distraction from patient

and co-workers, lack of pharmacological knowledge with problems in calculations…” (Alrabadi

et al., 2021). Therefore, it is clear to see that the causes leading up to the commitment of a

medication error are incredibly multifaceted and run deeper than simple negligence. All of these

medication errors and others have substantial and irreversible impacts on patients and their

families. Medication errors can lead to a plethora of adverse reactions including allergic

reactions, overdose, psychological damage, cardiac complications, and death. According to a

journal article featured by the Joint Commission, “Medication errors (MEs) result in at least one

death each day and injure approximately 1.3 million people annually in the United States”

(Schroers et al., 2021). Each time a medication error occurs, a patient and their family members

lose more trust in the healthcare system. Medication errors can cause extensive psychological

and physical trauma to those patients and their family members.

Prevention is the key when it comes to avoiding medication errors. With regard to

administering a medication to the wrong patient, this can be avoided by verifying the identity of

the patient using two unique identifiers such as name and date of birth. Also verifying the room

you are entering is the correct room number can help prevent these errors as well. Dosage

calculation errors can be prevented by taking the time to perform calculations correctly and

completely. The nurse should also verify her calculations are correct with another nurse,
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especially when administering highly critical medications. Additionally, if the nurse is unable to

read a written order or is confused by the order, they should not hesitate to contact the provider

for clarification. To avoid administering the wrong medication to a patient, the nurse should

perform three medication checks at the Pyxis, after preparing, and at the bedside. They should

also verify or clarify orders with the provider as needed if any questions arrive. The best way to

prevent medication errors is to verify all five rights of medication administration have been

completed, in addition to practicing techniques to alleviate burnout and fatigue as these are also

major factors that contribute to medication errors.

Regarding my own future career as a nurse and nurse practitioner, medication errors are

something I am keenly aware of. Especially with the hope of becoming a provider as a nurse

practitioner, my medication calculation skills, order writing skills, and general medication

knowledge must be on point. I am most reluctant about performing a miscalculation and giving

the wrong dose of a medication as well as giving a medication at the wrong time. As a nursing

student, I know that one of my weak points is medication calculation and math in general, so

when it comes to orders written as “q 8 hours”, I can imagine trying to count forwards or

backwards from the current time may be something that could trip me up, especially if there are

time constraints or it is an urgent situation. I also know that having to complete a quick dosage

calculation involving someone’s weight for example may also lead to a medication error on my

end, again especially in the event of an urgent situation. The first step in preventing these errors

from happening is to have a strong sense of self-awareness regarding my weaknesses. Because I

am aware that dosing may be a weak point for me, I will be extra vigilant when preparing to

administer medications. Additionally, I will always have a secondary nurse check my

calculations if necessary, especially in the case of highly critical medications. Lastly, if ever I am
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unsure about a dose or frequency of a medication, I will not be hesitant to contact the provider or

pharmacist for clarification. Implementing these strategies in conjunction with practicing the 5

medication rights will prevent medication errors and improve patient outcomes.

Medication errors are some of the biggest contributors of sentinel events in healthcare

and are generally very preventable. This paper enhanced my understanding of medication errors

because prior to reading the research, I assumed that medication errors were simply the result of

nurses being negligent and not paying close enough attention. While this still is a major

contributing factor, the research indicates there are myriad reasons that lend themselves to more

of a system-wide issue rather than falling on just the nurses alone. Through researching, I also

learned just how significant an impact medication errors have on patient outcomes in regard to

the fatality and injury rate related to these errors. In the future, I will be more vigilant and self-

aware when preparing and administering medications because I will always think back to this

research and these statistics. If ever I do commit a medication error, I will make sure to fill out

an incident report and take full accountability for my mistake as this can help to prevent the same

medication errors from happening again as well as exemplifies professionalism in clinical

practice.
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References

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T. L., Al-Azzam, S. I., Al-Rabadi, D., Farha, R.

A., Alrabadi, S., & Al-Faouri, I. (2021). Medication errors: a focus on nursing practice. Journal

of Pharmaceutical Health Services Research, 12(1), 78–86.

https://doi.org/10.1093/jphsr/rmaa025

Schroers, G., Ross, J. L., & Moriarty, H. (2021). Nurses’ Perceived Causes of Medication

Administration Errors: A Qualitative Systematic Review. Joint Commission Journal on Quality

and Patient Safety, 47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010