Running head: REDUCING MEDICATION ERRORS 1

Reducing Medication Errors:

Giving the Right Patient the Wrong Medication
Venessa Rivera Colon
University of South Florida
REDUCING MEDICATION ERRORS 2

Medication errors in the medical field

Medication errors have great implications on the health and potential life of individuals.

It is estimated that an adverse drug event (ADE) occurs 1.5 million times annually in the United

States (Weant, Baker, & Bailey, 2014). At the patient level it presents risks to health by

increasing injury and exposure to death. Deaths due to medication errors are greater in the

United States than deaths due to car accidents, human immunodeficiency virus/AIDS, and breast

cancer collectively (Shahrokhi, Ebrahimpour, & Ghodousi, 2013). Between 44,000 to 98,000

deaths occur yearly with a cost between $6-29 billion for compensation of these errors

(Shahrokhi et al., 2013). Administratively it impacts providers by increasing lawsuits and

liability coverage, increased health care costs, and longer hospitals stays.

Administration of the wrong medication to the right patient

In the scheme of medication errors, administration of medication is the final step in

which an error can be prevented. Previous steps include, prescribing, transcribing, and

dispensing where errors can originate. A common medication error is giving the wrong

medication to the right patient. With the fast paced schedule that nurses have in balancing care

for multiple patients, there is room for error. A nurse may confuse medications and give the

wrong medication to a patient, potential causing injury or loss of life.

Nursing interventions to reduce wrong patient errors

There are interventions that nurses can implement to reduce medical errors specifically

addressing administering the wrong medication to a patient. Most measures are cost effective and

simple to implement. They include the use of the automated dispensing cabinets, creating Safe

Zones, and the utilization of bar codes.

REDUCING MEDICATION ERRORS 3

Utilizing automated dispensing cabinets

Hospitals have implemented the use of automated dispensing cabinets (ADC) which

indicate medication distribution according to patient. Nurses should always withdraw their

medications directly from the cabinet, not relying on any other employee to do so for their

patients. This will reduce the likelihood of giving the wrong medication to a patient.

Controlling interruptions through safe zones

Nurses need to maintain complete focus when administering medications. According to

Yoder, Schadewald, and Dietrich (2015), nurses have 14 interruptions per hour and 21% of

these interruptions occur during tasks such as medication delivery and verification when a high

risk to patient safety exists. Interruptions include, staff, patients, emergencies, and personal

matters. It is of utmost importance that nurses limit interruptions. Strategies include, notifying

colleagues that they are administering medications and avoiding other tasks until medications

have been distributed. A very effective strategy is the creation of Safe Zones that implement

quiet areas to prepare to administer medications, utilizing a check list for administration without

conversation, educating staff about avoiding conversations during administration, and utilizing a

sash to indicate no interruptions should occur (Yoder et al., 2015).

Utilizing bar coding systems

The use of bar coding systems has proven to be helpful in identifying errors in dosage

and drug. Additionally, according to Weant et al. (2014), it assists in ensuring compliance with

Joint Commission recommendations for the consistent use of two patient identifiers. By

verifying the patients identity, the likelihood of the wrong patient error is reduced.
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Personal reflection

Of all of the medical errors, my greatest concern is giving a patient another patients

medicine. I have observed multiple ways of medication distribution by the nurses I have

shadowed and observed techniques that I will implement into practice. As taught in our

program, I verify the medication at least three times, against the Medical Administration Record,

with the chart, and at the patients bedside. Prior to distribution of medications, I will look up

the patients lab values as well as ensure that they have very recent vitals taken. The software

that is used in the hospital provides lab values that permit or disallow medication distribution. I

will also employ an effective method that I have seen nurses use, the medicine bags with the

MAR printed per patient. Each patient has their own medicine bag with their name and

medication to reduce error. Additionally, when medications are scanned, the software informs us

if it is the correct medication and correct time. I will be very cognizant of the 6 rights, right

dose, time, patient, medication, route, and documentation. I entered this field to help patients and

do not harm to and it is my intent to keep that commitment.

Conclusion

With appropriate measures implemented to reduce medication errors, lives and careers

can be saved. It also serves as cost savings to providers. Facilities can take steps to reduce

medical errors for the livelihood of their patients.

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References

Shahrokhi, A., Ebrahimpour, F., & Ghodousi, A. (2013). Factors effective on medication errors:

A nursing view. Journal of Res Pharm Practice, 2, 18-23.

Weant, K., Bailey, A., & Baker, S. (2014). Strategies for reducing medication errors in

the emergency department. Open Access Emergency Medicine, 6, 45-55.

https://doi.org/10.2147/OAEM.S64174

Yoder, M., Schadewald, D., & Dietrich, K. (2015). The effect of a safe zone on nurse

interruptions, distractions, and medication administration errors. Journal of Infusion

Nursing, 38(2),140-151.