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Medication Errors
Heidi Bosmans
University of South Florida


Medication errors are a huge problem in hospitals that can lead to major
adverse outcomes for patients. Although making errors is a fact of being human, it
is the nurses responsibility to do everything possible to prevent a medication error
from happening. Even though medication errors can be caused by any member of a
health care team, they are most commonly caused by nurses (Cheragi et al, 2013).
Even if the error happens somewhere else, with the pharmacy or doctor for
instance, it is the nurses responsibility to try and catch those errors before they
reach the patient. There are many different types of medication errors. Each time a
medication is given, the nurse should ensure that he or she has the right medication
and the right dose given to the right patient through the right route, at the right
time, using the right documentation. A mess up in any one of these factors would
lead to medication error. In this paper, I will focus on medications given at the
wrong time.
Medication given at the wrong time is one of the most common medication
errors. According to a study done in intensive care units, 71.1% of medication errors
were that of doses being omitted, and 11.5% were of medication being given at the
wrong time (Teunissen et al, 2013). Many nurses do not view wrong time errors as
being as severe as other errors (Stokowski, 2012). However, there are many cases
when wrong time errors can be just as severe as any other medication error. In her
article about wrong time errors, Laura Stokowski uses insulin as an example. She
states, Giving a dose of insulin to a patient 1 hour after the morning dose was
administered could be a serious wrong-time error (Stokowski, 2012). Insulin given
at the wrong time could results in hypoglycemia, which could be a major adverse
effect for the patient. There are many other medications for which administration is
time sensitive. For instance, some medications are best given at night time, and


some need to be given with food. With everything that nurses have to do in a day, it
is easy to miss a warning that says to give a medication at a specific time. In my
own clinical experience, I witnessed this nearly happen. When my nurse and I had
gone to get the patients 11 oclock nateglinide (Starlix), we realized the Pyxis was
out so the nurse called the pharmacy to send it the drug down. Nateglinide should
be given around thirty minute before eating, however the drug did not arrive from
the pharmacy until around one oclock, a large amount of time after the patient had
eaten his lunch. The nurse, however, was ready to give the medication until I
pointed out that it said to give before meals on the bag from the pharmacy. The
medication ended up being omitted until the next scheduled dose time, which was a
few hours later. Of course, it was not the nurses fault the Pyxis was out of the
medication or that the pharmacy took a long time to send it. However, this example
does show the importance of knowing about the medications one is giving, even if
one is in a hurry. To avoid errors such as these, Stokowski recommends that every
hospital form its own list of time-critical medications. Medications that should be on
every hospitals list, she states, are drugs with a dosing schedule more frequent
than every 4 hours, drugs that need to be given at a different time from other
drugs, drugs that need to be given before, with, or after food, immunosuppressants
used to prevent organ rejection, and scheduled opioids to prevent breakthrough
pain (Stokowski, 2012). By prioritizing these medications, a nurse stand lesser
chance of making a wrong time error that could be harmful to the patient.
Additionally, it is important to address something that is the cause of all
types of medication errors: distractions. According to The Effect of a Five-Part
Intervention to Decrease Omitted Medications, distractions and interruptions while
administering medications are the leading cause of medication errors. A study done


in 2005 showed that nurses are distracted about six times per hour during each
shift, with a majority of those distractions happening while giving medications
(Pape, 2013). Nurses are also frequently in a rush, which can lead to them not
properly reading a label and confusing medications, or not realizing the medication
was time sensitive, as was the case with my nurse and the nateglinide.
Interventions that can be implemented to prevent distractions while
administering medications include demarcating the medication room as a no talking
zone, and having nurses wear a vest or sash to indicate that they are in the process
of giving medications and should not be disturbed (Pape, 2013). By doing these
things, the nurse has a lesser chance of being distracted and making any type
medication error. It will also directly help reduce wrong time errors because the
nurse should be able to administer the medications in a timelier manner without
being held up with talking at the Pyxis or distractions in the hall.
I am definitely fearful of making a wrong time error, as I have witnessed they
can be very easy to make. Now that I am giving medications, it is much clearer to
me the stress of trying to get everything done on time. On a few occasions, when I
felt rushed because there was someone waiting behind me in the medication room,
I nearly pulled medications out of the Pyxis that were not scheduled until later in the
day. Luckily, either I or my nurse caught it before I took them out. This reminds me
to constantly be checking and rechecking the medications I am going to give to
make sure they are the correct ones for the time. When feeling rushed, it is possible
to make any type of error, not just wrong time. Recently, I took care of two patient
who had the same first name and middle initial, were close in age, and in rooms
right next to each other. They also had a couple medications in common. It would
have been easy to mix them up either when I was drawing medication out of the


Pyxis, or delivering them to the patient. I was able to avoid this by checking the
patient identifiers, the medications, and using the barcode scanner. I do not think it
is wise to have such similar patients next to each other, although patients room
assignments are not at my discretion. It does remind me, however, to be extremely
diligent in checking patient identifiers, and to avoid distractions. A distraction at any
point in the medication administration process for this already confusing patient
situation could have had extreme adverse outcomes.
In conclusion, opportunities for medication errors are abounding in a hospital
setting. At the heart of most medication errors, are distractions the nurse has while
administering medications. Whether the distraction leads to a time delay, or to
giving the medication to the wrong patient, it is a serious matter. Although many
nurses do not feel as if a wrong time error is as significant as another type of error,
one can see that there are many medications for which administration is time
sensitive. Therefore it is important to be aware of these medications and make their
administration a priority. Measures should be taken by hospitals to prevent a nurse
from experience interruptions while administering medications, such as making the
medication room a quiet zone, and having nurses wear something that indicates
they should not be disturbed. By reducing distractions and interruptions, every
single type of medication error can be reduced. Lastly, it is important to report any
medication errors or near misses, for the safety of the patient and so that such
errors can be prevented in the future.


Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types
and causes of

medication errors from nurse's viewpoint. Iranian journal of

nursing and midwifery research,

18(3), 228.

Pape, T. M. (2013). The Effect of a Five-Part Intervention to Decrease Omitted

Medications. Nursing

Forum, 48(3), 211-222. doi:10.1111/nuf.12025

Stokowski, L. (2012, October 16). Timely Medication Administration Guidelines for

Nurses: Fewer

Wrong-Time Errors?


TEUNISSEN, R., BOS, J., POT, H., PLUIM, M., & KRAMERS, C. (2013). Clinical relevance
of and risk factors associated with medication administration time errors. American
Journal Of Health-System Pharmacy, 70(12), 1052-1056. doi:10.2146/ajhp120247