Avoiding preventable harm

A medication error is an event that could or should have been prevented. It may cause or lead to inappropriate medication use or patient harm. Medication errors result in at least one death per day and injure approximately 1.3 million people annually in the United States alone. Globally, the estimated cost of medication errors is about $42 billion per year, almost 1% of health expenditures worldwide.

Nurses play a crucial role in preventing medication errors as a final check to determine whether a medication is correctly prescribed and dispensed before administration. However, medication administration is a complex process that involves a multidisciplinary team working together to provide patient-centered care. It is important to remember that the five “rights” alone do not guarantee administration safety.²

Error causes

Medication errors can happen due to assorted reasons, which can lead to severe harm, disability, and death²:

• Inadequate training
• Distractions/interruptions
• Fatigue
• Medication room overcrowding
• Staff shortages
• Taking shortcuts
• Skipping medication safety checks

Many remember the case of Radonda Vaught. In 2017, Vaught bypassed medication administration safety measures, changing the hospital’s computerized medication cabinet to “override” mode. This allowed access to medications that were not prescribed to the patient. Tragically, a potent paralytic was administered instead of the ordered sedative, which led to the patient’s death. Vaught’s license to practice nursing was revoked, and she was convicted of two felonies for her role in this error.

Error impact

Medication and other errors cause nurses to experience the following:

• Post-traumatic stress disorder (PTSD)
• Emotional trauma
• Clinical depression

Often termed the “second victim syndrome,” this is a serious issue that must be addressed to ensure the physical and mental well-being of healthcare workers.

In September 2010, Kimberly Hiatt (a critical care nurse at Seattle Children’s Hospital) administered ten times the normal dose of calcium chloride to an

infant in her care. The infant died five days later, and Hiatt was terminated from her nursing position. The Washington State Board of Nursing (formerly the Nursing Care Quality Assurance Commission) mandated a four-year probationary period that included medication administration supervision. Unable to secure new employment, Hiatt suffered from emotional depression and trauma as a second victim to a tragic medication error. Ultimately, she took her own life.^4,

According to a WSNA survey of Washington nurses conducted several months after Hiatt’s case, approximately 50% of the respondents believed that their mistakes would be held against them. Nearly one-third of the respondents stated that they were hesitant to report an error or a patient safety concern because they feared facing harsh retribution from management.

Medication error prevention

What’s new? What’s tried and true?

What’s new — Use barcode verification before medication and vaccine administration

Consistently use barcode verification for hospital inpatients whenever it is available in other clinical areas to support patient safety. High-risk areas include a short/limited stay (e.g., emergency department, infusion clinics, radiology, and outpatient areas). Review barcode medication compliance metrics available to identify successes and areas for improvement.

What’s new — Use independent double checks for selected high-alert medications

Implement strategies to improve high-alert medication safety. Be alert for gaps across the medication use process (i.e., prescribing, dispensing, administering, and monitoring) as the final check before administration. Limit the use of independent medication double checks to high-alert medications according to the facility’s policy on medications with the greatest risk of error.

› The ISMP endorses the selective use of independent double checks that target medications with the highest error vulnerability and greatest risk of patient harm. With workload and implementation challenges, such as limited staffing and work disruption, high-alert double checks still play a crucial role in patient safety. Perform independent double checks with a second qualified person. For more information: 2019 independent double checks.

What’s new — Prevent medication errors during transitions in care

Obtain an accurate medication list before administering the first dose of medication (except in an emergency). Inquire about allergies and reactions. Ask about prescriptions, over-the-counter medications, herbals/dietary supplements, and non-enteral medications. Elevate any medication discrepancies. Document medication lists and modifications to therapy on admission and transfer, and at discharge.

Tried and true — “Rights” of medication administration

The consistent use of the rights of medication administration is important for medication administration safety. It is particularly valuable in settings where barcode medication scanning is unavailable.

Safety culture

If you see something, say something

A culture that encourages the reporting of medication errors and near misses, regardless of the level of harm caused, is essential for patient safety. Nurses contribute to a culture of safety by reporting medication errors and near misses using their incident reporting system. This facilitates the review of error reports to identify common causes of mistakes and ways to improve. Working together, it is possible to prevent medication errors.