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Understanding Medication Errors in Healthcare

Medication errors are preventable events that can harm patients and occur at various stages of medication administration. Common errors include selecting look-alike drugs that are easily confused due to similar names or labels. Miscommunication over the phone when taking orders can also lead to errors if the SBAR method is not used. Overriding safety checks in dispensing systems like Pyxis increases error risk. Errors can seriously impact patients and their families. To avoid errors, nurses must know safe administration processes like the six rights and carefully triple check medications. As a student, focusing on one task and asking questions can help prevent mistakes.

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37 views6 pages

Understanding Medication Errors in Healthcare

Medication errors are preventable events that can harm patients and occur at various stages of medication administration. Common errors include selecting look-alike drugs that are easily confused due to similar names or labels. Miscommunication over the phone when taking orders can also lead to errors if the SBAR method is not used. Overriding safety checks in dispensing systems like Pyxis increases error risk. Errors can seriously impact patients and their families. To avoid errors, nurses must know safe administration processes like the six rights and carefully triple check medications. As a student, focusing on one task and asking questions can help prevent mistakes.

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© All Rights Reserved
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Medication Errors

Grace Andleman

University of South Florida


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Medication Errors

According to the National Coordinating Council for Medication Error Reporting and

Prevention, a medication error is clearly defined as “any preventable event that may cause or

lead to inappropriate medication use of patient harm while the medication is in the control of the

healthcare professional, patient, or consumer” (Tariq et al., 2022). Such medication errors can

occur when the provider is writing the prescription for the drug, when the drug is being prepared,

or when the drug is being administered to the patient. There is room for error anywhere along the

line. Although there is no way to eliminate all medication errors, it is important to be aware of

the most common medication errors, identify look a-like drug labels, implement a safe plan to

improve health outcomes, and keep patients safe and free of harm.

Common Medication Errors

We are all bound to make mistakes throughout our life; it is a part of our human nature.

Some of the best lessons learned throughout life stem from making a simple mistake. Although

this is true, it is still imperative to recognize all the common medication errors so we can prevent

these mistakes from happening again.

Look-alike Drug Label Errors

One of the most common medication errors happens when the provider, nurse, or

pharmacist accidentally selects the wrong medication after entering only the first few letters of

the drug name. Some examples of medications that are commonly confused because they look a-

like and sound-alike are clonidine and clonazepam, dopamine and dobutamine, and zerit and

zyrtec. It is recommended that when looking up the medication the first five letters are typed out

at the bare minimum. This could have resulted in a better outcome for RaDonda Vaught in 2019.

This RN entered the first two letters of the drug she was supposed to pull into the Pyxis machine.
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By mistake she selected and removed the wrong medication; verconium instead of midazolam

(Versed). Unfortunately, this medication error happened to be one that was irreversible and one

that killed the patient. Therefore, it is important to triple check what you are administering to the

patient when pulling the medication in the med room and at the bedside.

Misheard Drug Orders via Telephone Communication

Although the EMR or MAR is the main source of communication for providers when it

comes to new orders, orders can also be given over the phone. It is common for people to

mishear or misunderstand what the other person on the other line may be saying. For that reason,

healthcare professionals should implement the SBAR technique which provides a solid

framework for communication over the phone. The situation, background, assessment, and

recommendation are given, as well as a readback at the very end. The readback allows the other

colleague to make sure that everything said was clearly understood. This would include the time,

patient, drug, route, dose, etc.

Overriding Drugs via Pyxis

Even though the pyxis machine promotes safety and reduces the number of medication

errors in the field of healthcare, there is an overuse of overrides. This overuse results in

medication errors. More often than not, these medications that are unnecessarily removed. In

order to minimize the risk of harm and medication errors, healthcare workers should not override

unless deemed necessary and make sure that there is an order placed in the EMR for the

appropriate patient.

Impact on Patients & Families

Whether it be due to a simple mistake or greater systemic issue having to do with the

healthcare facility, medication errors can result in death, life-threatening situations, birth defects,
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disabilities, and many other irreversible situations for the patient. Not only are the patients

themselves impacted by medication errors, but their family members are impacted as well. They

can leave loved ones devastated knowing that their family member’s death or injury could have

been easily prevented; this can eventually affect their mental and emotional well-being

(Robertson & Long, 2018). Families may also hinder from seeking medical attention and

develop a form of mistrust in the healthcare system and its providers.

Avoiding Medication Errors

To avoid medication errors from occurring it is important that nurses know the process

for safe medication administration. This includes knowing the patient’s health history, following

the orders given, triple checking the medications against the MAR before the patient takes them,

and always assessing the patient before and after the medications are given. Along with that, the

nurse should perform the six rights of medication administration: right drug, right dose, right

route, right time, right patient, and right documentation. These nursing interventions will help

each of the common medication errors from happening.

Impact on Students

As a student nurse there are a handful of different thoughts running through my head

before passing meds. Of course, there are fears of committing a medication error by accident.

Some of these fears include accidentally passing the wrong medication to the wrong patient or

losing track of time. To ease my fears, I will commit to know the process for safe medication

administration, perform the six rights, focus on one task at a time, tune out all distractors, and

ask questions. I believe that implementing this plan will help me reduce the chance of

accidentally committing a medication error.


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Conclusion

Although the Pyxis machine does a great job at reducing several medication errors, it is

still not perfect; mistakes can still be made. That being the case, recognizing medication errors,

the common ways that they are committed, and how our mistakes can affect others has allowed

me to fully understand how important my role is as a student nurse and when I become a

registered nurse in the near future. This paper has allowed me to not only keep myself

accountable, but others as well, and allow others to correct me if I am not meeting the

professional standards when it comes to passing medication to my patients.


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References

Robertson, J. J., & Long, B. (2018). Suffering in Silence: Medical Error and its Impact on Health

Care Providers. The Journal of emergency medicine, 54(4), 402–409.

[Link]

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication Dispensing Errors and

Prevention. In StatPearls. StatPearls Publishing.

Common questions

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The Pyxis machine is effective in reducing medication errors by promoting safety through controlled medication dispensing. However, its effectiveness is limited by its susceptibility to human error, particularly from unnecessary overrides. Overuse of overrides can lead to medications being dispensed without proper orders in the EMR, increasing the risk of errors. Thus, while the machine reduces errors, proper use protocols are crucial to maximize its effectiveness .

The SBAR (Situation, Background, Assessment, Recommendation) technique is significant in reducing miscommunication-related medication errors by providing a structured framework for conveying information. It enhances communication by ensuring that all pertinent details are covered systematically, which helps in clarifying the patient's needs and the circumstances around a medical order. Additionally, the readback step in SBAR allows for verification and correction of any misunderstandings, thus minimizing the chance of errors through verbal orders .

Common causes of medication errors include mistakes in writing prescriptions, preparation, and administration of drugs. Factors contributing to these errors include look-alike drug labels, misheard drug orders via telephone communication, and inappropriate overrides of medication dispensing systems like the Pyxis machine. To mitigate these errors, it is recommended to implement interventions such as accurately typing out the first five letters of drug names, utilizing the SBAR technique for phone communications, and avoiding unnecessary use of overrides in dispensing systems .

Medication errors significantly impact the education and practice of student nurses, who often experience anxiety over the possibility of making errors. These errors prompt educators to emphasize the importance of mastering safe medication administration processes, including the six rights: right drug, dose, route, time, patient, and documentation. By focusing on these practices, students can build confidence and competency, which helps them in preventing errors and fostering a culture of safety in future professional practice .

Healthcare systems play a crucial role in creating environments that can prevent or contribute to medication errors. Systems designed with robust safety protocols, comprehensive training programs, effective communication strategies like SBAR, and technologies such as the Pyxis machine help in reducing errors. Conversely, environments lacking in these elements, where systemic issues such as workflow inefficiencies and improper use of technology exist, often contribute to the incidence of errors. Proper oversight and continuous improvement of healthcare processes are essential for minimizing errors .

Medication errors can have severe consequences for healthcare providers, including emotional and psychological distress. They may suffer from guilt, anxiety, and decreased job satisfaction, knowing their actions could have resulted in patient harm or death. This emotional toll can also lead to burnout and a loss of confidence in their professional abilities, potentially affecting their overall performance and commitment to patient care .

Healthcare organizations can foster an environment conducive to openly discussing and learning from medication errors by developing a non-punitive culture that encourages reporting and analysis of errors without fear of retribution. Implementing regular training sessions, multidisciplinary team meetings, and debriefings on identified errors can help in identifying systemic flaws and preventing future incidents. Additionally, creating robust feedback mechanisms and integrating findings into practice improvement ensures that lessons from errors are continually reviewed and applied .

The six rights of medication administration are the right drug, right dose, right route, right time, right patient, and right documentation. These principles are critical in preventing medication errors as they provide a comprehensive framework for ensuring all aspects of drug administration are correct. By adhering to these rights, healthcare professionals can significantly reduce the likelihood of administering incorrect treatments, thereby improving patient safety .

Beyond immediate physical harm, medication errors can have a profound psychological and emotional impact on patients and their families. Affected family members might experience devastation, knowing the harm or death of their loved one could have been prevented. This can lead to mistrust in the healthcare system and may deter them from seeking future medical attention. Furthermore, the emotional distress can have lasting effects on their mental well-being .

To prevent look-alike drug label errors, healthcare professionals should take measures such as typing out the first five letters of a drug's name when searching in systems to ensure accuracy. They should also implement a multi-step verification process, including triple-checking medications at different stages before patient administration. Training programs and system alerts highlighting look-alike medications can further reduce these types of errors .

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