Medication Error

Medication administration is a very important part of a registered nurses’ job. Multiple medications, patient issues, and technology all contribute to the complexity of medication administration. A medication error is defined as ‘any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer’. In addition an error can also be the wrong drug, route, dose, preparation, time, technique, or documentation. Errors can be a serious problem for patients’ health. (Härkänen, Ahonen, Kervinen, Turunen, & Vehviläinen-Julkunen, 2015)

The Study A low number of errors are reported, about 10-20%, in clinical practice and very few are

The team comprised of five registered nurses, five pharmacists, and two physicians. This team found and classified the errors based on seriousness. The observation was done by two independent individuals with a background in nursing. The observers followed the registered nurses as they administered medications to one hundred twenty two patients. The medication lists and the pharmacist dispensed medications were compared by the observers before the registered nurse began administering the medications. The observers also collected information about the experience of the registered nurse, the patient-nurse ratios, if the nurse double shaded medications, and/or if the nurse asked for help from other workers. The route, timing, rate, and handling of the medications were recorded. If a nurse appeared nervous, sick, or tired it was noted on the observation form. All distractions such as phone calls, noise, and interruptions were noted. The observations made were compared with the electronic medication list for the patient to check the route, dose, and timing matched up. All the data was reviewed by the professional team and the errors were classified by severity ranging from no harm to death. (Härkänen, Ahonen, Kervinen, Turunen, & Vehviläinen-Julkunen,

63.4% (149) were administration errors and 18.3% (43) were documentation errors. Out of the administration errors, 37.9% (89) were wrong technique and 26.8% (63) were omission. In about 24.3% (57) of cases, the error was caught before reaching the patient. In 51.1% (120) of cases, the error reached the patient but did not cause any harm. The rest of the errors, 21.3% (50) required monitoring to make sure there was no harm to the patient. Out of these errors, 3% (7) caused temporary harm and required intervention, and in one case, 0.4%, the error caused the patient to remain in the hospital longer. (Härkänen, Ahonen, Kervinen, Turunen, & Vehviläinen-Julkunen,