Medication Errors 1

Medication Errors

Michael Sandin

NUR3215L

University of South Florida

Medication Errors

There are many types of errors that can go on in the nursing profession, and for any

health care job considering the consumers are people that need some form of medical care. This

could be preventative care, care conducted in acute settings, or care in out-patient settings. All of

these settings and care performed by health care professionals pose potential risks. One of the

tasks performed so often by nurses happens to be one of the tasks that pose a great amount of

risk for errors is medication administration. During medication administration, a cause of

medication error that is of particular important because of how prevalent it is would be

distractions and interruptions. When discussing distraction errors, its important to go through

what sort of errors are currently occurring in the nursing field, what are distractions and

interruptions nurses experience, and what are some possible solutions to this problem.

First of all, what is the definition of a medication error? One study covered medication

administration errors in hospitals, and used the definition that a medication error is a deviation

from a prescribers medication order as written on the patients chart, manufacturers instructions

or relevant institutional policies. (Keers RN, Williams SD, Cooke J, Ashcroft DM., 2013) This

study essentially covered the different types of medication administration errors. It found that of

the medication errors reported by nurses, slips and lapses was among the most common, making

up 53.7% of what was reported. Slips and lapses were mostly seemingly simple errors made by

the provider like misreading or misidentifying things related to the medication. This also

included medications had similar characteristics like names. The same study found that other

errors included not knowing enough about the medication, the infusion pump, the physical health

of the nurse, inadequate training, procedures, poor communication, or even the patient who the

nurse was giving the medication to. (Keers RN, Williams SD, Cooke J, Ashcroft DM., 2013)
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With this study identifying much of the more common medication errors, procedures like going

through the six rights of medication administration before giving each medication, or seeking out

the correct information and teaching for something you dont know become even more relevant.

One of the causes of medication errors thats harder to control is interruptions. A nurse is

subject to a multitude of interruptions. from various sources. Workplace distractions are

generally hard to control, but several studies have brought up ways to help reduce medication

errors caused by distractions. One such study about the effect of a safe zone when relating to

distractions and medication errors by Yoder, M., Schadewald, D., and Dietrich, K. notes that an

environmental factor correlated with increased MAEs is distraction during medication

preparation. The statistics provided for this essentially stated that about 6.7 interruptions at

work occurred per hour. (Biron AD, Loiselle CG, Lavoie-Tremblay M.) Other studies related to

the amount of distractions experienced by a nurse gave similar numbers, which further shows

how work place distractions can relate to medication errors. The study conducted by Yoder, M.

and colleagues goes on to explain what exactly constitutes interruptions, stating that

interruptions can be caused by individuals (eg, health care professionals, patients, family

members) or inanimate objects (alarms, missing or malfunctioning equipment). Nurses can be

interrupted though face-to-face conversations, phone calls, call lights, bed alarms, missing

supplies, malfunctioning equipment, and emergency situations. (Yoder, M., Schadewald, D.,

Dietrich, K., 2015) The article goes on to mention that must of these interruptions were from

conversation between other people. Many of these distractions are not really avoidable, but the

distractions that are should be managed by the nurse. Yoder, M., et. al. goes on to explain how

these distractions actually leads to medication error. Its essentially explained that these errors

remove the attention from medication preparation and administration, which potentially causes
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errors. (Yoder, M., et. al., 2015) This makes sense, in that to remove these errors, you reduce the

risk of the nurses attention being diverted away from what medications the patients on, whether

or not all the vitals and lab values were properly checked, or whether or not the dose of the

medication made sense for the patient.

The same study brought up a potential solution to these medication errors related to

distractions. Yoder, M. and colleagues propose creating a safe zone project during medication

preparation and administration. In a hospital, the new safe zone protocol created quite areas for

nurses to obtain and prepare medications, created a checklist for the procedure, staff education

about no distractions during medication administration, and had the participants wear a special

indicator that signaled they were either preparing or administering medication. (Yoder, M., et.

al., 2015) Those giving medications were then asked to rate the frequency of interruptions on a

0-10 scale. However, despite the implementation of the project, nurses and students reported an

increase in distractions and interruptions from pre- to postintervention. (Yoder, M., et. al., 2015)

Despite the failure of this study to produce less interruptions for nurses and students, it did

highlight the issues of distractions relating to medication errors, and at least presented with a

possible solution to the issues. Other possible solutions can include teaching staff not to interrupt

nurses during medication administration, and generally having a hospital establish a quite area

for nurses to handle medication preparation.

Overall, medication errors come in a variety of forms. Errors related to distractions are

important to focus on as distractions cant always be avoided, but finding new ways to help

prevent those distractions can result in few distractions, and thus fewer medication errors.
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Works Cited

Biron AD, Loiselle CG, Lavoie-Tremblay M. Work interruptions and their contribution

to medication administration errors: an evidence review. Worldviews Evidence-

Based Nursing 2009; 6(2):70-86

Keers RN, Williams SD, Cooke J, Ashcroft DM. Causes of Medication Administration

Errors in Hospitals: A Systematic Review of Quantitative and Qualitative

Evidence. Drug Safety. 2013;36(11):1045-1067. doi:10.1007/s40264-013-0090-2.

Yoder, M., Schadewald, D., & Dietrich, K. (2015). The Effect of a Safe Zone on Nurse

Interruptions, Distractions, and Medication Administration Errors. Journal of Infusion

Nursing, 38(2), 140-151. doi: 10.1097/NAN.000000000000000095