A Literature Review About Mecication Errors

Custom Student Mr. Teacher ENG 1001-04 22 July 2016

A Literature Review About Mecication Errors


An error rate of 5% is acceptable in most industries, however, in the health care industry; one single error can result in death. (Berntsen, 2004, p5) This paper discusses medication errors in relation to pharmacology and drug treatment. It will summarize three academic peer reviewed journal articles, followed by general information in relation to medication errors, the impact of medication errors on client care, strategies to prevent medication errors and conclude with the relationship to nursing.

Summary of Articles Related to Medication Errors.

The first article is by Karin Berntsen, 2004, and is entitled “How Far Has Health Care Come Since ‘To Err is Human’? Exploring Use of Medical Error Data”. This is a review of what changes have been made since a medication error report written by the Institute of Medicine was published in 1999. This article depicts how the health care system has changed since this 1999 report was written, and how the information was utilized for our benefit. They concluded that in the USA, medical errors were one of the top 8 leading causes of death. They reported the cost for these errors was between $17 Billion to $29 billion dollars. Until a new report is completed, health care providers will be unaware whether their goals in increasing patient safety were accomplished. The article finalizes that there has been progress in regards to prevention of medication errors and health care leaders feel passionate about increasing patient safety. (Berntsen 2004)

The second article is by William N. Kelly, 2004, and is titled “Medication Errors: Lessons Learned and Actions Needed” and highlights the death of a one year old child who was diagnosed with cancer. She subsequently died, not from the cancer, but from receiving an incorrect dosage of a drug that she was being treated with. This report indicates that medications are systematically checked and balanced and errors are usually caught before a drug is administered to a patient. The article states that problems are not being solved in a timely manner since the industry has been “putting ‘band aids’ on problems that need ‘major surgery’.(Kelly 2004). In conclusion, the article questions whether or not they are taking the right approach in preventing errors. Many people are trying to fix this problem however; errors are still made too frequently. (Kelly 2004)

The final article is by Rosemary M. Preston, 2004, and is titled “Drug Errors and Patient Safety: A Need for Change in Practice”. This article presents that errors continue to happen for many reasons. It concentrates upon calculations errors, lack of knowledge of drugs, over/under dosing drugs, interactions with drugs and food, and legalities regarding drug administration. It also presents recommendations to minimize the risk of drug errors with good communication and honesty. The article closes by stating that “nurses should never estimate the skills needed for safe administration of medicines.” (Preston 2004)

Key aspects: medication errors and their causes.

To understand the impact that medication errors have on a patient, we have to understand what a medication error is. According to Health Canada online, 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.” [Developed for use by the National Coordinating Council on Medication Error Reporting and Prevention]( http://www.hc-sc.gc.ca/english/index.html)

Medication errors occur for a variety of reasons. An error can affect all areas of a health care facility from health care management, staff, physicians, pharmacy and especially patients. Studies have indicated that errors will usually occur when the staff demonstrates signs of fatigue, stress, are over-worked or encounter frequent interruptions and distractions. When physicians display bad handwriting, ineffective communication with patients, and do not educate staff and patients effectively, a medication error is more likely to happen. Poor management can result in more medication errors when there is an emphasis on volume, over service quality. This results in inadequate staffing and disorganization. Medication errors affect all components of the health care environment. (http://www.napra.org/docs/0/95/157-/166.asp)

Impact on client care.

As disturbing as it sounds, one miniscule error can result in a patient’s injury or can even lead to their death. According to the American Journal of Medicine, statistics reveal that “more than two million American hospitalized patients suffered a serious adverse drug reaction in relation to injury within the 12-month period and, of these, over 100,000 died as a result.” http://www4.nationalacademies.org/news) Death and injury is a sad reality to any single error.

The government established six rights of drug administration to prevent medication errors and ensure accuracy. These six rights include: Right drug, right dose, Right client, right route, right time and right documentation. (Kozier & Erb 2004)

Injuries that result from a medication error are called adverse drug events. Usually, these unpleasant effects can be eliminated and injury can be avoided. However, every drug produces harmful side effects, but the severities of these effects vary from individual to individual. These side effects also depend on the drug and the dose given. (Kozier & Erb 2004)

Health care professionals must report all errors and are accountable for their actions. No matter how insignificant, nurses are taught to document and report all mistakes. When statistics show what types of errors are made, an analysis can be done. This analysis can be used to plan ways to prevent them medication errors. (Berntsen, 2004)When a nurse does not report a mistake, the probability that it will happen again will increase.

Medication errors have a huge impact on client care. They can result in death, injury, and result in unwanted effects of drugs. It is our responsibility as nurses to comply with the clients’ six rights of drug administration, to prevent errors from taking place.

Strategies to prevent medication errors.

There are many efficient ways to prevent nurses from making an error. To ensure patient safety in all aspects of client care, nurses are taught to think critically, and to problem solve. Nurses use critical thinking to ensure safe, knowledgeable, nursing performance and they must be able to keep up with updated health facts by constantly educating themselves with new information. (Kozier & Erb 2004) Critical thinking assists in the prevention of medication errors.

The six rights in drug administration help prevent medication errors from occurring. It is important to maintain the highest standards of practice of these rights for a drug to be prepared properly. Failure to adhere to any one of these rights will definitely result in a medication error. (Clayton & Stock, 2004)

Take your time when preparing medications and research any unknown drugs. Rushing should be avoided when preparing, administering and reading medication labels. Proper research must be done before an unfamiliar drug is administered it to a client. Even when in a rushed emergency situation, drugs should be looked at carefully to know the correct concentration and name of the drug, to prevent injury. (http://www.hc-sc.gc.ca/english/index.html)

Labels should be read carefully and accurately. Before a drug is given to a patient, three checks should be done to ensure you are giving the proper drug and dose. In a situation where you are unsure of a drug order, you are expected to refuse the order and clarify it by law. If an individual is unfamiliar with a particular drug, the drug should not be given. (http://www.napra.org/docs/0/95/157-/166.asp)

When a label is unclear, do not try not to examine the drug order yourself. Do not ask an associate, or ask for anyone else’s interpretation of the drug. To get the correct information, contact the individual who ordered the drug to clarify the label. In order to decrease the chances of error, verify all unclear hand writing, abbreviations, decimal points, decimal places and dosages. (http://www.napra.org/docs/0/95/157-/166.asp)

Use of dosage abbreviations should not be used to avoid drug miscalculations. Dosage abbreviations are misinterpreted more often, than any other type of abbreviation. Using standardized abbreviations, would assist in preventing misinterpretation of abbreviations. (Preston 2004)

A drug check should be done three times prior to the administration of a drug. The drug label should correspond with the physician’s orders. The three checks should be done; “Before removing the drug from the shelf or dosage cart, before preparing or measuring the actual prescribed dose, and before replacing the drug on the shelf or before opening a unit dose container, just before administering a dose to a patient.” (Clayton & Stock, 2004)

Do not make assumptions regarding drugs. Physicians, pharmacists, make mistakes and other parts of the health system may be flawed. For example, when documentation shows the patient has no drug allergy, it is wrongful to assume the patient will have no adverse reaction to a new drug. This could result in detrimental results to a client’s health. Therefore no assumptions should ever me made. (http://www.ismp.org-/ToolsAllina-Orientation.html)

A quiet environment for preparing medications will prevent prescription errors from occurring. Sometimes, nurses are repeatedly interrupted when preparing a medication. Distractions interfere with processing information and decision making. Errors will least likely occur when preparations are done when there are no distractions. (http://www.ismp.org-/ToolsAllina-Orientation.html)

When preventing errors, staff must be certain all dosage calculations are correct and clarified. It may be beneficial to ask a colleague to assist you in checking doses, to minimize the chance of miscalculations. Other suggestions to minimize error include; “making pre-calculated conversion cards, always use a leading zero before a decimal, never use a zero after the decimal and include indications whenever possible. Miscalculations are preventable if proper methods of inspecting calculations are used.” (Preston 2004, p.72)

Assess for the effects of drugs to avoid harming a client. A client must be assessed before and after a drug is given. For instance, before giving an oral medication, assess whether the client can swallow or feels nauseated. An appropriate follow up should be done after a medication is administered. It is important to check if the client experienced the desired effect of the drug. Significant abnormal responses to drug should be reported to the physician. (Kozier & Erb 2004)


To finalize this assignment, medication errors are mistakes that can cause harm to patients and can even result in death. The articles that have been summarized illustrate situations where medication errors have occurred and review what the health care industry is doing to prevent errors. A medication error is preventable and errors can be caused by a variety of reasons. This paper has discussed the impact medication errors have on client care and strategies of how to prevent errors from occurring. As a nurse, this knowledge will assist me in keeping beneficence a priority for client care.


Clayton, Bruce D., BS, RPh, PharmD, and Yvonne N. Stock, MS, BSN, RN. Basic Pharmacology for Nurses. 13th ed. United States of America: Mosby, 2004.

Government of Canada Online. (2004, Summer). Retrieved July 18, 2004, from Health

Canada Web site: (http://www.hc-sc.gc.ca/english/index.html)

Kelly, William N. “Medication Errors.” Professional Safety 49: 35. Academic Search Elite. EBSCO. Assiniboine Community College. 22 July 2004 .

Government of Canada Online. (2004, Summer). Retrieved July 18, 2004, from Health

Canada Web site: (http://www.hc-sc.gc.ca/english/index.html)

Kozier & Erb, Barbara, et al. Fundamentals of Nursing. 7th ed. Upper Saddle River, New Jersey: Pearson Prentice Hall, 2004.

Minimizing Medication Errors. (n.d.). In NAPRA: National Association of Pharmacy

Regulatory Authorities. Retrieved July 17, 2004, from NAPRA: National Association of Pharmacy Regulatory Authorities Web site: http://www.napra.org/docs/0/95/157/166.asp

Preston, Rosemary M. “Drug errors and patients safety: the need for a change in

practice.” British Journal of Nursing (BJN) 13: 72. Academic Search Elite. EBSCO. Assiniboine Community College. 22 July 2004 .


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