MEDICATION ERRORS

Medications are therapeutic measures aimed at improving clients’ health. Medication administration is one of the most critical functions of nursing practice; and doses must be prepared, dispensed, and administered safely and appropriately (Cohen, 2007). When administered carelessly and incorrectly the consequences can be harmful and threatening to the life of a client. Tragic outcomes include increased hospital stay, acute or chronic disability, or even death.

Medication errors may also affect the nurse both emotionally and professionally and could result in loss of position, legal consequences, or loss of license to practice.

Numerous publicized medication errors have caused astonishment among members of the health care profession and society as a whole. According to current literature, despite technological advances, preventive strategies, systematic methods of reporting errors, and definitions of what constitutes error, medication errors continue to be one of the most common causes of client injury.

Hidle (2007-2008) estimated that 44,000 to 98,000 people die each year from medication errors. These errors are most prevalent in infants and children, where medication dosages are calculated by body weight or body surface area. These highly unscientific measures leave children more prone to be victims of medical errors than adults.

Hidle (2007-2008) also refers to medication errors related to clients with underlying diseases, such as impaired renal function, clients in intensive care settings because of complex medical diagnoses, and the large number of medications that nurses must deliver. Medication errors in ambulatory and outpatient settings were reported as related to lack of education concerning over-the-counter drug use and interactions with prescribed medications.

Snyderman (2008), a chief medical editor for a television station, reported that 1 in 15 hospitalized children is harmed each year because of medication errors. She estimated that this translates into 540,000 children each year being given the wrong medication or the wrong dose; and she added that the number might be even higher because community hospitals were not included in the investigation.

Information concerning medication errors has serious implications for health and safety of clients and warrants a collaborative approach with numerous strategies to prevent errors. The central role that nurses play in medication safety is a primary focus of this text and is based on the knowledge and understanding of careful and correct medication administration.

The Institute for Safe Medication Practices (ISMP) and the United States Pharmacopeia are two organizations actively involved in monitoring medication error reports, and they have developed strategies aimed at correcting the problem and educating personnel involved in the administration of medications. The Joint Commission (TJC), which provides accreditation to U.S. hospitals and health care facilities, is also working to achieve high client care standards in the U.S. health care system. One of its goals has been in the area of medication errors. TJC implemented National Patient Safety Goals, one of which is aimed at assisting health care facilities in the prevention of devastating medication errors. Technological advances in terms of medication administration (e.g., use of bar coding, computerized unit dose medication carts) have been instituted in many facilities as a means of preventing and decreasing medication errors; however, computer technology cannot replace human intellect or negate the need to follow various steps in medication administation to ensure client safety.

Medication errors can occur anywhere in the distribution process, and when an error occurs, the cause can involve multiple factors. Michael Cohen, president of ISMP, in the book titled Medication Errors (2007), cited some causes of medication errors, such as the following:

Other causes of medication errors include errors in mathematical calculation of dosages, incomplete orders, failure to observe the six “rights” of medication administration when administering medications, failure to identify a client accurately, and miscommunication of orders.

Miscommunication of medication orders can involve poor handwriting, misuse of zeros and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations.

Other contributing factors to medication errors include failure to educate clients properly about medications they are taking, administration of medications without critical thought, and failure to comply with the required policy or procedure related to medication administration. With the shortage of nursing personnel, factors such as shift changes, floating staff, double shifts, and workload increases have also contributed to errors. Certain medications, referred to as high-alert medications, have also been identified as contributing to harmful errors. The medications on this list include concentrated electrolyte solutions, such as potassium chloride. Other medications that are associated with harmful errors include heparin, insulin, morphine, neuromuscular drugs, and chemotherapy drugs.

Although advances in technology such as automatic dispensing cabinets (ADC), computer prescriber order entry (CPOE), and bar-code medication administration have decreased the number of medication errors, it has been stressed that these advances are useful only if they are properly applied and if the systems are effective and efficient.

The reasons for medication errors are not limited to those presented and are not nursing errors alone. The best solution to the problem of medication errors is prevention. To prevent medication errors, personnel involved in the administration of medications must do meticulous planning and implement the task properly, paying close attention to detail.

The administration of medications is more than just giving the medication because it is what the health care provider ordered. The health care provider orders the medication; the nurse should know the action, uses, side effects, expected response, and range of dosage for the medication being administered. Nurses are accountable when administering medications and must understand the activity, indications, and contraindications of the full range of medications they may be called on to administer.

Medication administration involves using the nursing process, which includes assessment, nursing diagnosis, planning, implementation, evaluation, and teaching clients about safe administration.

CRITICAL THINKING AND MEDICATION ADMINISTRATION

There are numerous definitions for critical thinking. The best way to define critical thinking is as a process of thinking that includes being reasonable and rational. Thinking is based on reason. Critical thinking is important to all phases of nursing but is particularly relevant in the discussion of medication administration.

Critical thinking encompasses several skills relevant to medication administration. One such skill is the ability to identify an organized approach to the task at hand. For example, in medication administration, calculating dosages in an organized, systematic manner (formula, ratio and proportion, dimensional analysis) decreases the likelihood of errors.

A second skill characteristic of critical thinking is the ability to be an autonomous thinker—for example, challenging a medication order that is written incorrectly rather than passively accepting the order. Critical thinking also involves the ability to distinguish irrelevant information from that which is relevant. For example, when reading a medication label, the nurse is able to decipher from the label the information necessary for calculating the correct dosage. Critical thinking involves reasoning and the application of concepts—for example, choosing the correct type of syringe to administer a dosage, and using concepts learned to decide the appropriateness of a dosage. Critical thinking also involves asking for clarification of what is not understood and not making assumptions. Clarifying a medication order and dosage indicates critical thinking. Checking the accuracy and reliability of information decreases the chance of medication errors. The ability to validate information requires a high level of thinking and decreases the chance of medication errors that could be harmful to the client.

Critical thinking is essential to the safe administration of medications. This process allows a nurse to think before doing, translate knowledge into practice, and make appropriate judgments. To safely administer medication the nurse must base decisions on rational thinking and thorough knowledge of medication administration. Proper medication administration involves evaluation of the client and the medication’s effects, which requires critical thinking and skills of assessment. A nurse who administers medication in a routine manner, rather than with thought and reasoning, is not using critical thinking skills.

FACTORS THAT INFLUENCE DRUG DOSAGES AND ACTION

Several factors influence drug dosages and the way they act, including the following:

All these factors affect how clients react to a medication and the dosage they receive, and all must be considered when medications are prescribed and administered. Because of differences in the actions and types of drugs, clients respond in various ways, and therefore dosages must be individualized. No two clients will respond to a medication in the same manner. Nurses must keep these factors in mind when administering medications. These factors can account for individuals responding differently to the same medication.

SPECIAL CONSIDERATIONS FOR THE ELDERLY

Elderly individuals can be considered high-risk drug consumers. Approximately two thirds of older adults use both prescription and nonprescription drugs, and one third of all prescriptions are written for older adults. With the number of individuals over the age of 65 rapidly increasing, the use of medications in this age-group will also increase. According to the Administration on Aging (AOA, 2007), the older population (persons 65 years or older) numbered 37.3 million in 2006 (the latest year for which data are available). It is estimated that by the year 2030, there will be approximately 71.5 million older persons, more than twice their number in 2000.

People are now living longer, and older people tend to use health care services more often. As with children (see Chapter 25), special consideration should be given to the client who is over 65 years of age. With the aging process come physiological changes that have a direct effect on medications and their action in the elderly individual. Aging causes the slowing down of the body’s functions. Other physiological changes include a decrease in circulation, slower absorption, slower metabolism, a decrease in excretory functions, and a decrease in the ability to respond to stress such as the stress of medications on the system. Other changes with aging include a decrease in body weight, which can affect the dosage of medications, and changes in mental status, possibly caused by the effects of physical illness or physiological changes in the neurological system that can occur with aging. These physiological changes can cause unexpected medication reactions and make the elderly person more sensitive to the effects of many medications.

According to Michael Cohen (Medication Errors, 2007) 90% of the elderly take prescription medications and of those who use at least one prescription drug, almost half use five or more medications. An estimated 25% to 30% of hospital admissions of elderly patients are linked to medication-related problems. Because the elderly are often taking more than one medication (polypharmacy), problems such as drug interactions, severe adverse reactions, drug and food interactions, and an increase in medication errors occur. The Beers criteria list medications that should be avoided in clients age 65 years and older and with certain medical disorders and that place the client at unnecessary risk. It is recommended that practitioners be aware of the medications on this list and educate clients regarding prescription and nonprescription medications. As the senior population continues to increase, there is a need to focus on reducing medication errors in this group.

As a rule, the elderly client will require smaller dosages of medications (as dosage size increases, the number of adverse effects and their severity increase), and the dosages should be given farther apart to prevent accumulation of medications and toxic effects. With aging, visual and hearing problems may develop. Special attention must be given when teaching clients about their medications to help prevent medication errors. Develop a relationship with the client; building rapport and trust is important for the elderly. Take time and talk to the elderly, listen to what they say, and never assume they do not know how much or what medications they are taking. Ascertain that all instructions are written as clearly as possible, choosing fonts that are friendly to older eyes. Make sure the client has appropriate measuring devices to facilitate ease and accuracy when measuring (e.g., a dropper or measuring cup with calibrated lines to indicate small dosages [0.2 mg, 0.4 mg, etc.]). To lessen the chance of taking too much medication or forgetting a dosage, try to establish specific times compatible with the client’s routine for taking medications. Help the client to recognize pills by the name on the bottle, not by color. If the print on medications is too small for the client to read, encourage the use of a magnifying glass. Other measures might include providing a simple chart that outlines the medications to be taken, times they are to be taken, and special instructions if needed. Such a chart should be geared to the client’s visual ability and comprehension level. Encourage the elderly client to request that childproof containers not be used; some older people will have difficulty opening child-resistant containers. Recommend medication aids for the client, such as special medication containers divided into separate compartments for storing daily or weekly medication dosages. (Figure 10-1 shows examples of medication containers.)

When teaching elderly clients, it is important to remember that they are mature adults who are capable of learning; they may need and deserve additional time for learning to take place. Be patient, use simple language, and maintain the independence of the elderly as much as possible. Always allow ample time for processing, individualize the teaching, and remember to always foster feelings of self-worth. Correct teaching can decrease misunderstandings and errors in medication.

THE SIX RIGHTS OF MEDICATION ADMINISTRATION

When the nurse is administering medications to a client, the six rights of medication administration should serve as guidelines. Failure to achieve any of these “rights” constitutes a medication error. The six rights (Box 10-1) should be followed when administering any medication to avoid errors and to ensure client safety.

BOX 10-1   The Six Rights of Medication Administration

1. The right medication

2. The right dosage

3. The right client

4. The right route

5. The right time

6. The right documentation

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