Subscribe to Clinical Compass™ Volume 5, Issue 12 - June 15, 2010

Medication Errors: Continued Cause for Concern

by Christina J. Ansted, MPH, CCMEP

Since distribution of the neuroscienceCME Clinical Compass™ on medical errors in December of 2009, noteworthy events in the realm of medical errors have continued to occur. In this article, we’ll take a look at what’s happened over the last 6 months and examine the implications for patient care.

In April 2010, an article by Westbrook and colleagues published in the Archives of Internal Medicine looked at the association of interruptions with an increased risk and severity of medication errors. Interruptions in this context refer to instances when nurses are interrupted while in the process of administering medications. Conducted at 2 hospitals in Australia, the study hypothesized that interruptions have been implicated as a cause of medical errors and procedural failures. What they found was that among the nurses who participated in the study (a volunteer sample of 98 nurses [representing a participation rate of 82%] observed preparing and administering 4,271 medications to 720 patients over 505 hours from September 2006 through March 2008), the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors. Nurse experience provided no protection against making a clinical error and was actually associated with higher procedural failure rates.(1) Johanna I. Westbrook, PhD, from the University of Sydney in Sydney, Australia, and colleagues describe what happens during an interruption: "Experimental studies suggest that interruptions produce a negative impact on memory by requiring individuals to switch attention from one task to another. Returning to a disrupted task requires completion of the interrupting task and then regaining the context of the original task."

The take-home message is evident—reduction of nurse interruptions directly impacts medical errors. But the responsibility for this correction is multidisciplinary. In an accompanying invited commentary to the Westbrook article, Julie Kliger, BA, BSN, MPA, from the University of California-San Francisco notes that to reduce medication errors, interruptions need to be reduced.(2) "Who, exactly, is to be held accountable for high error rates in medication administration?" Ms. Kliger writes. "The answer seems clear, as confirmed by Westbrook et al: the entire professional medical, nursing, and administrative team. The time has come for nurses, physicians, pharmacists, and all hospital staff to align behind the goal of a safer medication administration process."

Published in the March 2010 issue of American Nurse Today, Pamela Anderson and Terri Townshend provide vignettes of real-life nurse-related medication errors:(3)

Situation 1
A critical care nurse tries to catch up with her morning medications after her patient’s condition changes and he requires several procedures. He is intubated, so she decides to crush the pills and instill them into his nasogastric (NG) tube. In her haste to give the already-late medications, she fails to notice the “Do not crush” warning on the electronic medication administration record. She crushes an extended-release calcium channel blocker and administers it through the NG tube. An hour later, the patient’s heart rate slows to asystole, and he dies…

Situation 2
A patient returns from surgery, anxious and in pain, with several I.V. lines and an intracranial pressure (ICP) monitor in place. The I.V. tubing used in the operating room differs from the tubing used in the intensive care unit (ICU). In her haste, the ICU nurse prepares to inject morphine into the patient’s ICP drain, which she has mistaken for the central line. She stops just in time when she realizes she’s about to make a serious mistake…

These examples illustrate the point of how easily serious and sometimes fatal medication errors can occur. Administration errors account for 26% to 32% of total medication errors—and nurses administer most medications. Unfortunately, most administration errors aren’t intercepted.(3)

In efforts to reduce the number of medication errors, nurses have typically followed the “5 Rights of Medication Administration,” which have now expanded to include 10 rights:

  1. Right Patient
  2. Right Medication
  3. Right Amount/Dosage
  4. Right Manner and Route
  5. Right Time
  6. Right Documentation
  7. Right Assessment
  8. Right Education
  9. Right Evaluation
  10. Right to Refuse to Medication
However, these “rights” have value outside the margin of medication administration and the role of the nurse, and may prove useful for other members of the patient care team.

Additionally, the Institute for Safe Medication Practices (ISMP) has identified 10 key elements with the greatest influence on medication use, noting that weaknesses in these can lead to medication errors;(3) they are:
  • Patient information
    • Accurate demographic information (the “right patient”) is the first of the “five rights” of medication administration.
    • Required patient information includes name, age, birth date, weight, allergies, diagnosis, current lab results, and vital signs.
  • Drug information
    • Accurate and current drug information must be readily available to all caregivers. This information can come from protocols, text references, order sets, computerized drug information systems, medication administration records, and patient profiles.
  • Adequate communication
    • Many medication errors stem from miscommunication among physicians, pharmacists, and nurses. Communication barriers should be eliminated and drug information should always be verified. One way to promote effective communication among team members is to use the “SBAR” method (situation, background, assessment, and recommendations).
  • Drug packaging, labeling, and nomenclature
    • Healthcare organizations should ensure that all medications are provided in clearly labeled unit-dose packages for institutional use. Packaging for many drugs looks similar.
    • Look-alike or sound-alike medications also are a source of errors. The Joint Commission requires healthcare institutions to identify look-alike and sound-alike drugs each year and have a process in place to help ensure related errors don’t occur.
  • Medication storage, stock, standardization, and distribution
    • Many errors could be prevented by decreasing availability of floor-stock medications, restricting access to high-alert drugs, and distributing new medications from the pharmacy in a timely manner.
    • Hospitals can use commercially available products to decrease the need for I.V. compounding medications and I.V. admixing. Use of preprinted order sets and standardized formularies can also reduce errors.
  • Drug device acquisition, use, and monitoring
    • Improper acquisition, use, and monitoring of drug delivery devices may lead to medication errors. In addition, syringes for administering oral medications should not be compatible with I.V. tubing.
  • Environmental factors
    • Environmental factors that can promote medication errors include inadequate lighting, cluttered work environments, increased patient acuity, distractions during drug preparation or administration, and caregiver fatigue.
  • Staff education and competency
    • Medications that are new to the facility should receive high teaching priority. Staff should receive updates on both internal and external medication errors, as an error that has occurred at one facility is likely to occur at another.
    • As medication-related policies, procedures, and protocols are updated, this information should be made readily available to staff members. Also, nurses should attend pharmacy grand rounds.
  • Patient education
    • Caregivers should teach patients the name of each medication they’re taking, how to take it, the dosage, potential adverse effects and interactions, what it looks like, and what it’s being used to treat.
  • Quality processes and risk management
    • Every facility should have a culture of safety that encourages discussion of medication errors and near misses (errors that don’t reach a patient) in a nonpunitive fashion. Only then can effective systems-based solutions be identified and used.
Tactics such as those mentioned above are useful in helping to prevent and/or reduce the overall incidence of medical errors, and should be routinely applied to clinical practice by nurses and physicians alike.

Medical errors can happen at any time, during any shift, with any patient, and in any number of ways. In addition to human checks and balances, technology offers strategies for reduction of medication errors. Bar-code technology and electronic medical records (eMR) are fairly recent advancements, which have shown promise in clinical application, and have been employed by hospitals across the country.

In May 2010, Poon and colleagues published an article in the New England Journal of Medicine on the effects of bar-code technology on medication administration. They conducted a before-and-after assessment of an academic medical center that was implementing bar-code verification technology within an electronic medication-administration system (bar-code eMAR).(4) Given the evidence that medication errors are most common after prescription and before administration, Poon and colleagues looked to see whether or not bar-code eMAR effectively reduced rates of errors in order transcription and medication administration. Of the observed 14,041 medication administrations and 3,082 order transcriptions reviewed, observers noted 776 non-timing errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)—a 41.4% relative reduction in errors (p < .001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (p < .001). The rate of timing errors in medication administration fell by 27.3% (p < .001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR, but were completely eliminated on units that did use it.(4) Poon and colleagues therefore concluded that use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events. And that although it did not eliminate such errors, the bar-code eMAR improved medication safety.(4)

Though bar-code and eMAR technologies have been heralded as valuable tools to improve patient safety, these technologies are expensive, requiring a substantial financial and also human resource investment. In a press release about the implementation of these technologies into the hospital system, lead author Eric G. Poon, MD, MPH, from Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, commented: "Our study shows that this combination of technologies can make the delivery of hospital care safer. However, hospitals need the right set of resources and human talent to deploy these technologies successfully, so more research is needed to identify ways to implement them in the most cost-effective way.”

Until such time as bar-coding and electronic medical records become commonplace, medical staff with direct patient care responsibilities must use the tools and guidelines available to them, such as the “rights” of medication administration mentioned earlier and national patient safety recommendations. But they must also work together to implement processes that address the causes of medical errors (e.g., nurse interruptions, long shifts without adequate breaks or recovery time between shifts, and misinterpretation of prescriptions).

Patient Safety Goals and Resources
In a poll conducted in December 2009 by CME Outfitters, 25% of respondents said that they were not at all aware of the 2009 JCAHO National Patient Safety Goals, and only 29% were either very or extremely aware of the sentinel event alert regarding the ‘zero-defect’ approach to medical errors—see poll results here.

In response to continued vigilance against medication errors, the Joint Commission has posted 2010 National Patient Safety Goals on their website in new easy to read versions,(5) and can be accessed at These safety goals, which will become effective as of July 1, 2010, focus on problems in health care safety and how to solve them, and advise clinicians to institute practices such as those presented in this article. Clinicians and hospital staff are strongly encouraged to become familiar with these goals and make adjustments to their practice patterns to improve patient safety.

Resources on the impact of medical errors and how to avoid them are available at the following websites:(3) Check and recheck, then check again. Have repetitive processes in place, such as phone verification of prescriptions by the pharmacist, or verification with the prescribing physician by the nurse of the name, dose, and route of administration of any medication prior to dispensing and administering to the patient. Mandatory implementation of such procedures should be strongly considered by hospital administrative staff. As is frequently the case in many facets of our lives, the devil is always in the details, and never is it truer than when dealing with medication errors.

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  1. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010;170:683-690.
  2. Barclay L, Lie D. Interruptions Linked to Medication Errors by Nurses. MedscapeCME Clincal Briefs 2010;MedscapeCME. Available at
  3. Anderson P, Townsend T. Medication errors: Don’t let them happen to you. American Nurse Today 2010;5:23-27.
  4. Poon EG, Keohone CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, Moniz T, Rothschild JM, Kachalia AB, Hayes J, Churchill WW, Lipitz S, Whittemore AD, Bates DW, Gandhi TK. Effect of bar-code technology on the safety of medication administration. N Engl J Med 2010;362:1698-1707.
  5. The Joint Commission. National Patient Safety Goals. 2010. Available at

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