Running head: Medication Errors and Prevention

Medication Errors and Prevention

Desiree Hartzell
University of South Florida

MEDICATION ERRORS AND PREVENTION

Medication Errors and Prevention

Medication errors are an all too common event in the healthcare system that can lead to
increased encumbrance of illness to patients as well as thousands of dollars per year in
unwarranted healthcare costs (Redley & Botti, 2013, p.579). Nurses and other healthcare staff
should be taking specific protocols to avoid medication errors, but the last stop between the
incorrect drug and the patient is normally the nurse. In which case, nurses in all facilities
(i.e. hospitals, nursing homes, rehabilitation facilities, etc.) should be taking the steps to prevent
medication errors, these steps are called the six rights (Bennett, 2008). The six rights
include: the right drug, right patient, right route, right time, right dose, and the right
documentation (Bennett, 2008). This method is taught throughout most nursing education
programs as well as in healthcare facilities during training. These six rights are in place for the
safety of the patient and the protection of the licensed nurse, should they follow them properly.
Facility Adjustments to Prevent Medication Errors
Even though the six rights method is full proof in theory to prevent medication errors,
there are still incidences of medication errors involving omission of these details or other
unforeseen obstacles. This being said, there have been multiple changes that healthcare facilities
have implemented to prevent medication administration errors, such as, the introduction of
electronic medication tracking systems (i.e. medication administration record MAR),
computerized scanning systems, and automated dispensing systems (i.e. Pyxis Medstation)
(Redley & Botti, 2013, p.582). Even though multiple steps are taken to avoid medication errors,
the issue still persists, though the incidence has decreased significantly. A study performed by
Bernice Redley and Mari Botti on medication errors compared the use of electronic medication

MEDICATION ERRORS AND PREVENTION

administration systems to the conventional pen and paper tracking system, determined that the
facility utilizing the electronic system displayed 60% fewer incidences of medication
administration errors as well as less severe outcomes to the drugs errors, such as documentation
errors as opposed to dosing errors (2013, p. 585). Therefore, medication administration in
healthcare settings is not a perfect system, but with diligence on the part of the healthcare
professionals and utilization of current administration tools, medication errors can become less
prevalent.
Medication Error Examples and Correction
In the hospital setting I have witnessed two potential medication errors that may have
been an extreme hazard to the patient had it not been caught. One of the errors was caught by the
nurse performing the six rights. The computer and the pharmacy did not catch the dosage issue
when the medication was being prepared and scanned into the MAR. The nurse only caught the
dosing error when she read the original labels on the packaging. The second error was not caught
by the nurse at all, as he did not perform the six rights for medication administration. The drug
was placed in the wrong slot in the Pyxis, the nurse failed to check the drug, the computer
scanned the medication and failed to note the error, in which case the patient made the difference
in this potentially dangerous error. The patient, who was educated on her medications, was able
to say to the nurse, this is not my medication; I takethe doctor ordered It was then that the
nurse checked the MAR and realized the mistake. These are examples of human and electronic
failure that can lead to potentially harmful medication errors.

MEDICATION ERRORS AND PREVENTION

Conclusion
As a nurse, I will not just rest on the physicians orders, the MAR, or the automated
medication systems to administer medications. Administering medications is an important
responsibility that takes time, diligence, and responsibility. When I am giving a medication I will
be completely confident that I have checked all of my six rights as well as confirmed with the
automated systems. All of these things working together is the only way that medications can be
delivered correctly and safely; neither part should be omitted as patient safety is the highest
priority.

MEDICATION ERRORS AND PREVENTION

References
Bennet, J. (2008). Medication errors: managing the risk. Long-Term Living, 57(5), 50-52.
Redley, B., & Botti, M. (2013). Reported medication errors after introducing an electronic
medication management system. Journal Of Clinical Nursing, 22(3/4), 579-589.
doi:10.1111/j.1365-2702.2012.04