Aziz Fatimah Nursing College

Medication Administration Errors

Submitted To
Ms. Madiha

Submitted By
Rimsha Boota

Ayesha Sidiqa

Javaria Zafar

Shuja-Ur-Rehman

Shazza Akmal

BSN (2018-2022)
 Table Of Content

Sr. Page
Contents
No No.

1 Case Scenario 2

2 Introduction of Medication administration errors 2

3 Literature Review of Medication administration errors 4

Incidence & Prevalence of Medication administration

4 7
errors

5 Causes of Medication administration errors 8

6 Ways to Reduce Medicine Administration Errors 9

7 Conclusion of Medication administration errors 10

8 Recommendations of Medication administration errors 11

9 References 14

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 Case scenario
The case selected in this study is medication administration errors that occur most frequently
in the ward and these occupy most of the hospital-acquired diseases. In the medical ward,
nurses were preparing for medicine administration at noon. The senior nurses were busy in
their work so much that one of the staff nurses use the already used injection on another
patient. The incident was acknowledged by the client's attendants, when they told the nurse
that, the syringe that they brought for injection was unused after the nurse administered the
medicine. Is there a need for nurses to acknowledge and prevent such errors to reduce the
chance of cross-infection?

Introduction
Errors in the administration of medicine are common and can compromise the safety of the
patient. This review discusses the causes of drug administration errors in hospitals by
students and registered nurses and the practical measure, educators and hospitals can take to
improve nurses’ knowledge and skills in medicine management and reduction in making drug
errors. Patient safety and quality care are key aspects of effective healthcare systems and a
principal goal for healthcare providers in all healthcare settings. Care that accommodates the
individual needs of clients increases patient safety and, in turn, enhances the quality of care.
Multiple causes of Medication administration errors can be grouped under categories such as
inadequate knowledge, failure to follow policy and procedures, communication failures, and
individual and systems issues. Variations from standards of practice, preoccupation and
attention slips, interruptions, distractions, and inadequate staffing are also frequently cited.
Nurses perceive medication errors to be caused by several factors such as heavy workload,
distractions, interruptions, and experience. Several studies have validated these perceptions,
particularly linking interruptions, distractions, and medication errors. Among all patient-
centered standards, the safety of medication administration is considered a vital indicator of
health care quality. The National Coordinating Council for Medication Error Reporting and
Prevention stated that medication errors can occur while the medication is under the control
of health care providers, patients, or consumers. These errors are avoidable occurrences that
could cause or potentially cause incorrect medication use and/or harm to patients. Medication
errors occur during the prescription, transcription, dispensing, preparation, distribution, and
administration of medication.

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 The complexity of the medication administration process and the involvement of
different health team members increase the potential occurrence of Medication errors.
(Lambert et al., 2019) stated that medicine administration errors, wrong doses, missing doses,
and wrong medication are the most commonly reported medicine administration errors. This
narrative systematic review found caregiver medication administration rates from 1.9% to
33% of all medicine administration errors. Medicine administration errors are typically
thought of as a failure in one of the five “rights” of medication administration (right patient,
medication, time, dose, and route). These five rights of medication give a standard process to
safe medication administration. The first report related to medication error was presented in
1940. The administration of medication to a patient is one of the most valued nursing
practices. Performing it safely is among the most crucial professional responsibilities of
nurses. Nevertheless, it is becoming increasingly difficult to fully maintain patients’ safety
during the process of medication administration. Although nurses are involved in most of the
incidents of medication administration errors, they also are on the front line of health
professionals for the safe administration of medications, and also for Medication
administration errors from happening to patients. Medication error has the potential to lead to
harm to the patient.
It is the leading cause of threatening trust in the healthcare system, inducing
corrective therapy, and prolonging patients’ hospitalization, producing extra costs and even
death. This study aimed to assess medication administration errors and associated factors
among nurses. Poor communication with other nurses when they had problems was another
factor significantly associated with medication administration Patient safety and quality care
are key aspects of effective health care systems and a principal goal for healthcare providers
in all healthcare settings. Among all patient-centered standards, the safety of medication
administration is considered a vital indicator of health care quality. Medication administration
error is any preventable act that contributes to the failure of proper medication use in the
treatment process resulting in harm for the patient to the extent of disability and death.
Medication errors affect human relationships, threatens trust in the healthcare system
as a whole, and can also destroy life. (Fekadu et al., 2017) concluded that errors in
medication administration can occur through failures in any of the ten rights which are right
patient, right medication, right time, right dose, right route, right education/advice, right to
refuse, right assessment, right evaluation/ response, and documentation. Health workers

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committed medication administration errors during the processes of ordering, prescribing,
dispensing, preparing, or administration.

Literature Review
(Tsegaye et al., 2020) conducted a study in Tigray regional state of Ethiopia which
revealed that wrong dose, administering at the wrong time, medication omission,
administering a wrong patient, administering via a wrong route, administering un-prescribed
medication, and administering a wrong drug were the most common types of medication
administration errors. These errors can be prevented with consistent reporting systems and by
avoiding barriers to report the errors such as fear, heavy workload, time constraints, and
negative employee perceptions of error. The method used to conduct this study was cross-
sectional which based on a questionnaire that was used to collect data on nurse's socio-
demographic characteristics (salary, an institution where the nurse earned, an educational
award, year of experience, etc.), work-related factors (nurse to patient ratio, lack of written
guideline for medication administration, poor communication with other nurses while
facing problems, current working unit, lack of reporting mechanism to medication errors and
duration in specific unit), professional related factors (lack of training and inability to follow
ten rights of medication administration practice), and other factors contributing to a
medication error (Unclear verbal order, illegible physicians handwriting, wrong prescription
and dispensing, look like drugs, nurses prescription in place of physicians, nurse administer
medication prepared by another nurse and physicians frequent alteration of their orders). A
structured observational checklist that contained nine medication administration rights was
used to gather data on a total of 42 nurses. The results concluded in this study discovered that
Wrong time (38.6%) was the most frequently perpetuated Medication administration error
followed by wrong assessment (27.5%) and wrong evaluation (26.1%).
(Thomas, 2017) Conducted another study to describe interruptions, distractions, and
cognitive load experienced by registered nurses during the administration of medications and
to examine the relationship between interruptions and distractions on cognitive load. The
method used to conduct this study was hierarchical. Information collected regarding the
participating RNs included their gender, education, experience, employment status, RN-to-
patient ratios, shift worked, and sequence of the shift. Structural observation sheet, NASA
task load index, and self-report about distraction experienced during medication error, were
the tools used to evaluate the risk and extent of medication administration error. The results

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proposed that there is a significant independent relationship between a nurse having a
distraction, a nurse having an interruption, the number of interruptions experienced during a
medication administration episode, and each cognitive load measurement (mental demand,
temporal demand, physical demand, effort, and frustration). Nurses with any distraction had a
greater perceived mental, temporal, and physical demand, as well as effort and frustration
levels for the medication administration task, compared with nurses who did not have any
distraction. 
(Ali et al., 2021) concluded that MAEs are vital issues that affecting patient safety in
clinical fields worldwide. A number of adverse effects caused by MEs decrease the patient’s
prognosis. The estimated cost of these errors to the US government is around the US $17 to
the US $29 billion per year. The investigation of ME incidents can enhance the health care
system and decrease the risk of new errors. ME reporting depends on the Capabilities,
potential, and will of physicians, pharmacists, and nurses to identify the errors and report
them. In some events, nurses experience difficulties in reporting errors. This problem may
originate from an organizational culture of blame and the lack of support for such practice.
The most frequent sources of MEs are nurses, followed by physicians and pharmacists. The
authors also uncovered a number of issues that cause ME incidence, including heavy
workloads and errors committed by inexperienced staff to fill this gap. The recent research
illuminated these issues, with particular focus on the perceptions of Jordanian nurses.

(Salami et al., 2019) conducted a study in which they found the extent medication
errors of medication administration errors among nurses of Jordan hospitals. Patient safety
and quality care are key aspects of effective healthcare systems and a principal goal for
healthcare providers in all healthcare settings. Care that accommodates the individual needs
of clients increases patients’ safety and, in turn, enhances the quality of care. Among all
patient-centered standards, the safety of medication administration is considered a vital
indicator of health care quality. Medication administration errors (MAEs) are estimated to
harm 1.5 million people annually and account for almost 7.6 of 1000 outpatient deaths and
1.2 of 1000 inpatient deaths annually in the United State. The National Coordinating Council
for Medication Error Reporting and Prevention stated that medication errors can occur while
the medication is under the control of health care providers, patients, or consumers. These
errors are defined as any avoidable occurrences that could cause or potentially cause incorrect
medication use and/or harm to patients. Medication errors occur during the prescription,
transcription, dispensing, preparation, distribution, and administration of medication. The

5
complexity of the medication administration process and the involvement of different health
team members increase the potential occurrence of such errors. Nonetheless, it is the nurse
who has a primary role in medication administration. This study had 4 questions from a
Jordanian nurse’s point of view: (1) What are the types of MAEs? (2) What are the perceived
contributing factors for Medication Administration errors? (3) What is the impact of “shift
work” on Medication Administration errors (4) What are the preventive interventions
suggested by nurses to reduce MAEs? The MAEs consisted of the following in descending
order: wrong time (32.6%), wrong patient (30.5%), wrong dose (17.1%), wrong route
(14.8%), and wrong medication (5.0%). Similarly, MAEs due to route error were direct IV
medication administration, continuous IV infusion, oral, intramuscular, subcutaneous, and
other routes. Clinical experience is a critical issue in preventing MAEs. The literature
indicates that more than one-third of nurses admitted that their MAEs took place when they
were new graduates. This study provides an understanding of the types of MAEs and
perceived contributing factors among nurses working in a hospital setting. The high levels of
MAEs in relation to patients’ rights are alarming. The findings of this study provide health
care policymakers and nurse leaders with a better understanding of the contributing factors
that increase the rate of MAEs that jeopardize patients’ safety. Furthermore, the results of this
study should guide nurse educators to reinforce training in pharmacology and medication
administration. This study also provides valuable knowledge about the factors necessary to
reduce medication errors. Having a quality assurance program in relation to medications and
medication administration in all Jordanian health care settings is paramount to ensure patient
safety.

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 Incidence & Prevalence

(Pham et al., 2011) stated that medicine administration errors, wrong doses, missing doses,
and wrong medication are the most commonly reported medicine administration errors. This
narrative systematic review found caregiver medication administration rates from 1.9% to
33% of all medicine administration errors. According to (Weingart et al., 2000), Medication
administration errors are typically thought of as a failure in one of the five “rights” of
medication administration (right patient, medication, time, dose, and route). These five rights
of medication give a standard process for safe medication administration. The first report
related to medication error was presented in 1940.

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 Causes of Medical Error
According to the Agency for Healthcare Research and Quality, there are eight common root
causes of medical errors which include communication breakdown which is the most
common cause of medical errors. (Lesar et al., 1997) stated that whether verbal or written,
these issues can arise in a medical practice or a healthcare system and can occur between a
physician, nurse, healthcare team member, or patient. Poor communication often results
in medical errors. Information flow is critical in any healthcare setting, especially within
different service areas. Insufficient information flow happens when necessary information
does not follow the patient when they are transferred to another facility or discharged from
one component or organization to another. Human problems occur when standards of care,
policies, processes, or procedures are not followed properly or efficiently. Some examples
include poor documentation and labeling of specimens. (Heard et al., 2012) reported that
knowledge-based errors also occur when individuals do not have adequate knowledge to
provide the care that is required at the time it is needed. These may include inappropriate
patient identification, inadequate patient assessment, failure to obtain consent, and
insufficient patient education. These issues can include insufficiencies in training and
inconsistent or inadequate education for health care providers. Transfer of knowledge is
critical in most areas specifically where new employees or temporary help is used. Inadequate
staffing alone does not lead to medical errors but can put healthcare workers in situations
where they are more likely to make a mistake. Technical failures can include complications

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or failures with medical devices, implants, grafts, or pieces of equipment. Often, failures in
the process of care can be traced to poor documentation and non-existent, or inadequate
procedures.

Ways to Reduce Medication Errors

(Senst et al., 2001) concluded that Medication errors can be reduced in following ways.
Confirm that the patient weight is correct, write the weight on each order, and make sure that
the weight-based dose does not exceed the adult dose. Ensure that calculations are correct.
Induce the dose and volume of medication when appropriate and specify the exact dosage
strengths to be used. Right intravenous fluid orders ensure that additives are quantified per
liter and rates noted per hour. Write out all instructions rather than using abbreviations and
make instructions specific Avoid the use of terminal zero to the right of the decimal point to
minimize 10-fold dosing error (i.e. use 5ml rather than 5.0) Use zero to the left of a dose less
than 1, to avoid tenfold dosing errors (for example use 0.1 ml rather than 01 ml). Use a
computerized order entry system and standing order sets when available. Avoid the use of
verbal orders when possible. We recommend that nurses and pharmacists should always
check medications and calculations.

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 Conclusion
The common cause of errors mistakable drugs and names of medicines which look-alike
patient cases are a wider component of quality care nurses administered drugs directly to
patients and they are the last links in the safe medication administration change So always
used proper steps for administering medication by using these steps that desire described in
our study we prevent medication errors. Lack of training, unavailability of guidelines for
medication administration, interruption during medication administration, poor
communication when faced with problems, and failure to follow the ten rights of medication
administration were factors significantly associated with medication administration errors.
Therefore, stakeholders like the regional health bureau, hospital administrators, and nurse
professionals should collaborate and share respectively responsible to minimize problems
owing to medication administration errors. Medication administration error prevention is
complex but critical to ensuring the safety of patients. Providing continuous training on the
safe administration of medications, making medication administration guidelines available
for nurses to apply, creating an enabling environment for nurses to safely administer
medications, and retaining more experienced nurses may be critical steps to improve the
quality and safety of medication administration.

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 Recommendations
According to (Hartnell et al., 2012) the pharmacy environment is often fast-paced and
intense, with high prescription volume, insufficient staffing, and demanding patients.
Keeping pharmacy counters clear and clutter-free can be challenging, but it is an important
part of reducing the risk of dispensing errors, said Matthew Grissinger, RPh, director of error
reporting programs at the Institute for Safe Medication Practices in Horsham, Pennsylvania.
He advises pharmacies to use a basket system to keep different patients’ prescriptions and
drugs separate, as well as to clear away the bottles from prescriptions that have been
completed. Ideally, he said, pharmacists should take phone calls in a quiet, distraction-free
area. For prescriptions called in by phone, it’s important to write down and then repeat the
order to verify that it was heard correctly; ISMP recommends spelling drug names during
reading back. E-prescribing comes with its pitfalls, according to Dixie Leikach, vice
president of Catonsville and Paradise Professional Pharmacies in Catonsville, Maryland. Her
pharmacy often deals with problems caused by improper use of the technology. For example,
sometimes prescribers can’t find the correct drug strength or dosage form on the e-
prescribing dropdown menu, so they select a similar drug from the list and then write the
intended product in notes in other areas of the prescription, which can be missed during order

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entry. “We’ve learned over time that we have to read all the information and clarify if
something doesn’t make sense,” Leach said. Scanning barcodes plays an important role in
checking that the correct drug, dosage form, and strength have been selected, Grissinger said,
ensuring that the most common dispensing errors are avoided. But he cautions that in the
retail environment, this will only work if orders are entered into the system before selecting
the drug bottle; if pharmacists pull the wrong drug off the shelf and enter its NDC number,
barcoding will not catch that error because the incorrect barcode will be appear on the
prescription label. At Boulder Community Health (BCH) in Boulder, Colorado, where
Christopher Zielenski, PharmD is the pharmacy clinical coordinator, the use of barcoding
throughout the system, from dispensing through administration, has resulted in a huge
reduction in errors. Since they began requiring barcode scanning for medications being
placed in automatic dispensing cabinets, the rate of mistakes in filling medications has
been reduced to nearly zero, he reported. ISMP maintains a long list of drugs with similar
names that may be confused, which it recommends printing in bolded tall man (uppercase)
letters (egbuPROPion/busPIRone). Pharmacists must stay informed about what those drugs
are, experts said. Grissinger advised that every pharmacy choose 5 common LASA pairs and
develop strategies to avoid errors with them, such as separating them. If drugs are separated,
he cautioned, pharmacists and techs need to know where they are located. Leikach said that
LASA lists grow as more drugs become available in generic formulations. She gave
risperidone and ropinirole as an example. “When those were brand names, they weren’t a
problem, but once they both went generic and they’re both available in the same strength...
and they’re sitting next to each other on the shelf, all of a sudden you’ve got a huge potential
for pretty severe med errors and adverse drug effects.” One way to prevent human error is by
involving a second human-a pharmacist or technician (as permitted by state law)-in the
dispensing process. “If I’m the one taking the prescription and entering it, then I’m not
pulling the drug and counting it, because I know I have to final check it,” Leikach said.
“Someone else, a tech or another pharmacist, will look at it... We check each other.” When
she worked in environments where there was no one else there to check, she would walk
away from prescriptions once she’d reached a certain point in the dispensing process, so that
she could come back with “a fresh set of eyes.” Grissinger cautioned that final checks should
always include verification of the original order entry, whether by keeping the paper
prescription with the label and medicine bottle until completion or by pulling up the scanned
prescription on the computer screen. Various alert strategies can be helpful, but human nature

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is to overlook the familiar. That’s why Leikach moves around shelf-talkers alerting staff
about LASA drugs so they continue to catch the attention of staff members. She has also
requested that the pharmacy software system change some alerts to hard stops so that the
pharmacist or technician is required to stop, read the alert, and type a response-thus ensuring
that they pay attention. Patients are their last line of defense when it comes to medication
errors, and investing a minute or 2 in speaking to them can reap huge dividends in catching
medication errors. Grissinger advises asking the patient when they pick up the prescription:
“Open the bag; is this what you were expecting? Look at the label, look at the name of the
drug, look inside the bottle if it’s a refill to make sure it’s what you got last time.” Basic
counseling can help ensure that patients understand what their prescription is for and how to
take it properly; it sometimes helps catch errors as well. Speaking to patients is also valuable
in obtaining an accurate medication reconciliation, Zielenski noted, which is why BCH has
instituted training in active listening for staff involved in medication reconciliation.
"Pharmacists need to recognize their role to the patient,” Leikach said. “When you receive a
prescription-especially if you get to know your patients-then if something doesn’t make sense
don’t just let it go.” Question the patient and call prescribers to verify, she advised, and if
necessary, dig deeper to obtain clarification on why something was prescribed as it was and
whether it was a mistake. (Patanwala et al., 2012) stated that after enough occasions of being
thanked by prescribers for catching their errors, Leikach realized that “you do need to push
when you feel that something isn’t right,” she said.
“Let’s not keep waiting for things to go wrong and fix them,” Grissinger said. Experienced
pharmacists can sense when things are not going right and should address those concerns, he
said. “Otherwise something’s going to go wrong and the pharmacist is going to get blamed
for that when we saw it coming a mile away.” (Schenkel, 2000) concluded that ISMP has free
self-assessment tools that pharmacists in different practice settings can use to evaluate how
well they are maintaining patient safety.
Sometimes, Zielenski said, simple changes can have a big impact. For example, BCH started
stocking batteries on the floors after pharmacists realized that barcode medication
administration rates were dropping due to scanner batteries running out. Similarly, BCH
includes dosing and administration instructions with emergency kits. “Those types of tools
can be implemented anywhere,” he noted. “Frontline staff can develop them; it doesn’t have
to come from a manager”. 

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“I believe in reporting safety events-which are classified as near-misses and errors-even if
they are your own, to allow a big picture to develop so we can identify trends at the
system level and then address those issues and encourage peer-to-peer feedback,” said
Zielenski. He recently published an article describing how BCH developed several
interdisciplinary committees that used medication safety events reported through its voluntary
electronic safety event reporting system to perform continuous quality improvement
throughout the hospital. (Hanifin & Zielenski, 2020) stated that over 3 years, there was a
significant drop in rates of medication errors and a concomitant increase in the rate of near
misses, while reporting rates remained the same. Open discussion of medication errors is
most helpful when an institution has a just cultural perspective, Zielenski added. “As soon as
it becomes part of a normal conversation, I think that’s where you start to gain traction on
reducing medication errors,” he said.

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Fekadu, T., Teweldemedhin, M., Esrael, E., Asgedom, S. W. J. I. p. r., & practice. (2017).
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