Running head: MEDICATION ERRORS 1

Medication Errors in the Nursing Profession

Haley Higgins

University of South Florida

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Medication Errors in the Nursing Profession

In all areas of the healthcare profession, the main priority is to uphold patient safety while

providing efficient and effective medical care. Nurses play an essential role in safeguarding

patients rights and maintaining patient safety during the course of treatment; however, they are

not devoid of committing medical errors. Despite best efforts, medication administration errors

remain a problem for the healthcare community with approximately 20% of all medication doses

administered containing some type of error (Treas & Wilkinson, 2014). Research has identified

sources of medication errors and tested interventions that could be utilized to prevent these errors

from occurring.

Interruptions and Medication Errors

A common source of medication errors is the frequent interruptions experienced by

nurses during the medication administration process. Interruptions can result in the nurse

preparing an incorrect dose, obtaining an incorrect medication, and even administering

medication to the wrong patient. Several research studies have shown that interruptions are

commonplace in the hospital setting and can occur due to various stimuli. A research study

conducted by Hughes Cooper, Tupper and Holm (2016) monitored for interruptions during

medication passing on a medical-surgical unit at a hospital in Illinois. The study revealed that

interruptions occurred in 63% of medication passes, with an average of 1.5 interruptions per

medication pass (Hughes Cooper et al., 2016). The main sources of interruptions were telephone

calls, other medical personnel, and patients family members (Hughes Cooper et al., 2016).

A separate study conducted by Freeman, McKee, Lee-Lehner, and Pesenecker (2013)

monitored the medication administration process on a cardiothoracic surgical step-down unit.

The researchers observed an average of 3.29 interruptions per medication pass (Freeman et al.,
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2013). During this same time period, there were 41 reported medication errors on the unit

(Freeman et al., 2013).

Interventions to Prevent Interruptions

In order to combat frequent interruptions during medication administration, it is essential

that nurses be able to communicate with those around them that they are in the middle of an

important task and cannot be interrupted at this time. In a study conducted at Winchester

Hospital in Massachusetts, researchers discovered that 93% of morning medication passes were

interrupted (Capasso, Johnson, & Strauss, 2012). In an effort to reduce the number of

interruptions experienced by nurses while passing medications, the researchers implemented a

new procedure whereby the nurses attached a sign to the back of their computer monitors when

they began medication administration. After application of this new procedure, the percentage of

medication passes interrupted dropped to 50% with an average of just 1 interruption per

medication pass (Capasso et al., 2012).

In an effort to reduce the significant number of medication errors observed, Freeman et

al. (2013) implemented three interventions in the second phase of their study. These

interventions included a light-up lanyard worn with the nurses badge that was turned on during

medication administration, a no interruption zone in the medication room, and a telephone

triage system that prevented non-emergent phone calls from being transferred to the nurse during

peak medication administration times (Freeman et al., 2013). Over the next 3 months, the

researchers observed a 68% decrease in medication errors after the interventions were

implemented (Freeman et al., 2013). Another implementation that could be utilized to reduce

interruptions is placing medication dispensing machines in separate areas that are not accessible
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to anyone but the nurses. This will reduce interruptions from patients, family members and other

staff members while the nurse is preparing medications.

As a future nursing professional, the major concern I have regarding medication errors is

administering a medication to the wrong patient. In the acute care setting, nurses are

administering several drugs at once to each one of their patients, multiple times throughout their

shift. In addition to medication administration, nurses have several other tasks that they are

required to carry out simultaneously such as preparing patients for discharge or surgery,

interacting with and educating family members, and managing basic care needs of the patient. It

is easy to see how nurses can get side tracked in the midst of medication administration and

make an error. I believe the most important thing that I can do to prevent medication errors from

occurring is remain focused on the task at hand and be vigilant about carrying out safety checks

prior to administering any medication. Making sure that I check the patients wristband, ask the

patient their name and date of birth, and compare that information to what is on my medication

administration record will help reduce the risk of administering a medication to the incorrect

patient.

Conclusion

Medication errors are common place in the in-patient setting and can lead to severe

consequences for patients. Interruptions, regardless of their source, increase the risk of a nurse

making a medication error at some point during the medication administration process. The main

role of a nurse is to be an advocate for our patients and prevent any undue harm from occurring

while they are in our care. In order to fulfill this role, nurses must be aware of the potential

dangers that can arise during their shift and have mechanisms in place to prevent these situations

from occurring.
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References

Capasso, V., Johnson, M., & Strauss, M.B. (2012). Improving the medicine administration

process by reducing interruptions. Journal of Healthcare Management, 57(6), 384-390.

Freeman, R., McKee, S., Lee-Lehner, B., & Pesenecker, J. (2013). Reducing interruptions to

improve medication safety. Journal of Nursing Care Quality, 28(2), 176-185. doi:

10.1097/NCQ.0b013e318275ac3e

Hughes Cooper, C., Tupper, R., & Holm, K. (2016). Interruptions during medication

administration: a descriptive study. MEDSURG Nursing, 25(3), 186-191.

Treas, L.S., & Wilkinson, J.M. (Eds.). (2014). Basic nursing: concepts, skills, & reasoning.

Philadelphia, Pennsylvania: F.A. Davis Company. ISBN 978-0-8036-2778-9