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MEDICATION ERRORS

Medication Errors

Alaa Alkam

University of South Florida

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MEDICATION ERRORS
Medication Errors

In the United States, approximately 7,000 to 9,000 patients die each year due to

medication errors (Tarik, 2023). Despite advancements in healthcare technology and the

implementation of safety protocols designed to minimize the occurrence, medication errors

continue to occur causing death, psychological and physical pain, and increased health care

costs.

Medication errors represent significant and enduring challenges within the healthcare

sector, impacting patient safety and healthcare outcomes. In this paper I will discuss common

medication errors, the impact it has on patient health, and current preventative strategies.

Common Medication Errors

Medication errors can occur at any stage in the medication process, from the initial

prescribing to final administration of the drug. Commonly encountered medication errors include

issues such as, miscommunication errors, similar packaging between products (fonts & colors)

and, selection of wrong drug after entering the first few letters.

Miscommunication Errors

Miscommunicating verbal or telephone orders is a common problem when prescribing, or

giving orders, due to various factors like drugs having similar names, pronunciation errors, or

external distractions. This can be particularly problematic with drugs such as, clobazam and

clonazepam, risperidone and ropinirole, sulfadiazine and sulfasalazine, amlodipine and

nimodipine. Studies have shown that approximately 75% of medication errors have been due to

distractions (Tariq, 2023). Physicians have many responsibilities and duties to complete when

they are working and can easily prescribe the wrong medication or order, when they are rounding

to see their patients or are in a rush to see other patients.

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Look-alike Drugs

Another form of medication error could be due to similar packaging of products. Roughly

30% of medication errors are due to similar packaging and labeling. Below is an image of

infusion solutions that appear to look like the same product due to the same colors, fonts, and

writing. However, these solutions are in fact different. According to the Patient Safety Authority,

“8.7% of wrong-drug and wrong- concentration errors involve mix-ups between these solutions”.

Left: Dextrose 5% and Sodium Chloride 0.45% with Potassium Chloride 20 mEq
Right: Sodium Chloride 0.9% with Potassium Chloride 20 mEq

Similar packaging

Drugs with similar packaging and labeling as seen above can often be misidentified by nurses

and other healthcare professionals, posing a potential threat to patient safety.

Technology Errors
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While technology has decreased the rate of medication errors, there still exists the

potential for selecting the wrong drug, especially when only a few initial letters of the medication

are entered. Some nurses and doctors will only enter the first two or three letters of the

medication and a list of drugs will appear with those same letters. If they do not read the list

properly and select the first drug that is on the list, it can lead to a medicication error. For

example, chlorpropamide and chlorpromazine or dobutamine and dopamine. Nurses can easily

select the incorrect choice without confirming if it was the correct.

Avoiding Medication Errors

The errors discussed in the paper can be avoided by taking a few seconds to complete

necessary actions to confirm the correct medication.

Miscommunication errors can be avoided by reading back or repeating the drug name for

confirmation. One can also spell out the drug name if the drug has a similar phonetically

sounding name to another drug. Mix ups with look a-like drugs can be tricky especially when the

dosage is the only difference. However, a nurse should always double-check the name, dose, and

route of the drug before removing it from the dispenser. Another solution for a hospital is to

place the drugs in completely different cabinets/compartments. They should not be placed side-

by-side or in the same compartment to help reduce errors. As for technology errors, ISMP has

recommended that a minimum of 5 letters should be typed during searches to reduce selection

errors. Nurses should also confirm the name of the drug before removing it.

Medication name, dose, and route should be rechecked when they are in the room with

the patient to avoid errors.

Impact on Families
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Medication errors do not only impact the patient, but also their families. It could cause

emotional stress, especially if the error resulted in a death. A sudden unexpected death of a

family member can lead to anger, guilt, and anxiety. It can also lead to increased financial burden

due to additional treatments or rehabilitation services. Such incidences can lead to families not

trusting healthcare providers and the healthcare system affecting their decision to seek medical

care. Medical errors can cause a shift in family dynamics. For example, if the patient is the sole

income provider of the family or plays a significant role within the family unit, it can possibly

lead to a shift in the family roles and could lead to long-term instability.

Impact on Students

Like many nursing students, I share similar worries about medication errors. The fear of

inadvertently administering an incorrect medication to a patient, leading to their death. Or the

professional implications such as losing my nursing license or face legal punishments. To reduce

the risk of giving the wrong medication, I will follow the six rights of medication administration.

Triple-checking the medication, dosage, route, patient, and document everything. I always verify

that the information is accurate and matches the medication that has been prescribed. It’s

important to listen to the patient’s and families concerns because they might have information

that I was not made aware of. It’s also important to check for signs and symptoms of drug

toxicity and ask the patient how they are feeling.

Conclusion

In conclusion, as nurses we can reduce the amount of deaths and damage done by

medication errors by educating ourselves and those around us about the importance of adhering

to the rights of medication administration. It’s essential that we take responsibility for our actions

and care of our patients with the same respect and dignity that we would wish for ourselves –
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seeing them as individuals, not as a room number. The more we are aware about the deaths

associated with medical errors and how common it is becoming; we are more likely to be more

cautious with the drugs we give our patients.

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References

NHS. (n.d.). MHRA Warning – Watch out for look-alikes & sound-alikes. NHS choices.

https://medicines.necsu.nhs.uk/mhra-warning-watch-out-for-look-alikes-sound-alikes/

Pennsylvania Patient Safety Authority. (n.d.). Drug labeling and packaging-looking beyond

what meets the eye: Advisory. Pennsylvania Patient Safety Authority.

http://patientsafety.pa.gov/ADVISORIES/Pages/200709_69b.aspx

Schnoor, J., Rogalski, C., Frontini, R., Engelmann, N., & Heyde, C.-E. (2015). Case report of a

medication error by look-alike packaging: A classic surrogate marker of an unsafe

system. Patient Safety in Surgery, 9(1), 12. https://doi.org/10.1186/s13037-014-0047-0

Start the new year off right by preventing these top 10 medication errors and hazards. Institute

For Safe Medication Practices. (2020, February 18). https://www.ismp.org/resources/start-

new-year-right-preventing-these-top-10-medication-errors-and-hazards

Tariq RA, Vashisht R, Sinha A, et al. Medication Dispensing Errors and Prevention. [Updated

2023 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023

Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519065/