Medication Error Prevention

About this course

More than 100,000 medication errors are reported to the Food and Drug Administration each year. Medication errors occur because of environmental factors, unavailable medication information, and miscommunication of medication orders. There are many identifiable ways to reduce mediation errors, such as using the 6 rights to medication administration, medication reconciliation, and verifying new orders through double checking and read back techniques. Medication errors are preventable, and often result from not following proper policies in place for medication administration. This learning activity identifies potential risk factors that contribute to medication errors, and solutions that may be implemented when administering medication to reduce the risk of medication errors.

Learning objectives

• Define medication error
• Identify factors that can cause medication errors
• Identify solutions to reduce the risk of medication errors

Course outline

15 sections · finish in any order across devices

1. 1

   Introduction

   Accurate and safe medication administration depends a healthcare provider’s pharmacologic knowledge, decision making, and critical thinking skills. Consequently, medication administration is a high-risk task, as medication errors can result in poor patient outcomes. These errors may occur during any

   4 min

2. 2

   Medication Errors

   Medication errors can have serious and costly consequences, such as increased patient lengths of stay, additional medical interventions, serious harm, or even death. These errors can occur at any point during mediation usage, such as when it is prescribed, dispensed, and administered. Each year the

   4 min

3. 3

   Follow the six rights of medication administration

   The six rights to medication error include⁷:

   4 min

4. 4

   Follow Proper Medication Reconciliation Procedures

   Medication reconciliation is an important patient safety issue. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), a private, nonprofit organization whose mission is to continuously improve the safety and quality of care provided to the public, instituted the National Pat

   4 min

5. 5

   Double Check Prior to Medication Administration

   The double check should be conducted independently by a second healthcare provider to reduce the risk of bias that can occur when a healthcare provider who prepares and checks the medication sees what they expect to see. ⁴ An independent double check requires two healthcare providers to check each c

   4 min

6. 6

   Verify a Verbal Order Through Read Back

   Read back of a verbal order has long been practiced by the healthcare industry to reduce miscommunication when medical orders are relayed over the phone.⁵ To improve continued reduction in medication errors, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) included read back of

   4 min

7. 7

   Use a Name Alert for Common Names

   Many facilities use name alerts to prevent mediation errors resulting on patients with similar sounding patient names. For instance, similar names Smith and Smythe can result in medication error because of administering the medication to the wrong individual. ⁴ To prevent the confusion, many facilit

   4 min

8. 8

   Place a Zero in Front of the Decimal Point

   Errors in the dosage and strength of medications have occurred because of the misinterpretation that results from an absence of a leading zero in front of a decimal point such that .5 mg can be interpreted as 5 mg. ⁸ Also, the presence of a trailing zero behind a decimal point in numbers that are gr

   4 min

9. 9

   Correction

   μg

   4 min

10. 10

    Document Appropriately

    Medications should be documented as being administered on the appropriate documentation tool approved by the facility. To reduce the risk of a medication error, the medication record should never be altered. The healthcare provider should not erase, obliterate, or attempt to edit any note with corre

    4 min

11. 11

    Store Medications Correctly

    Ensuring proper storage of medications will assist in maintaining their efficacy until expiration. At the time of expiration, most drugs have 90% efficacy. The following suggests proper storage of medications within a facility.

    4 min

12. 12

    Eliminate Distractions

    Interventions that can be used to decrease distractions can reduce the risk of medication errors. Many healthcare facilities have implemented the sterile cockpit rule, which means eliminating distractions during medication preparation to avoid medication errors. This strategy was first developed and

    4 min

13. 13

    Conclusion

    To safeguard against medication errors, healthcare providers must implement the proper procedures for medication administration, including using the six rights and completing accurate documentation once the medication is administered. Failure to record the medication administered increases the risk

    4 min

14. 14

    Medication Error Prevention Posttest

    The healthcare provider must never compare the dose of medication ordered to the dose of medication that is available for administration.

    4 min

15. 15

    Medication Error Prevention Posttest Answers

    The six rights of medication administration include right patient, right medication, right dose, right route, right time, and right documentation

    4 min

This course satisfies

Requirement summaries come from our state requirement records. Always confirm details with your board before you renew.

References and resources

• 10 strategies for preventing medication errors. (2018, August 13). Retrieved from https://minoritynurse.com/10-strategies-for-preventing-medication-errors/
• Billstein-Leber, M., Carrillo, C. J., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493-1517. doi:10.2146/ajhp170811
• Gold, J. (2020). Unsafe medical abbreviations - Consumer med safety. Retrieved from https://www.consumermedsafety.org/tools-and-resources/medication-safety-tools-and-resources/know-your-medicine/unsafe-medical-abbreviations
• Independent double checks: Undervalued and misused: Selective use of this strategy can play an important role in medication safety. (2020). Retrieved from https://www.ismp.org/resources/independent-double-checks-undervalued-and-misused-selective-use-strategy-can-play
• Minimizing medication errors: Communication about drug orders - 2016. (2016). Retrieved from https://www.aao.org/patient-safety-statement/minimizing-medication-errors-communication-about-d
• The nurse’s role in medication error prevention. (2016). Retrieved from https://www.rn.com/nursing-news/nurses-role-in-medication-error-prevention/
• The six rights of medication administration. (n.d.). Retrieved from https://nurseed.blogspot.com/2011/03/six-rights-of-medication-administration.html
• To prevent ordering errors, one hospital is bringing "read backs" to the bedside. (2019, June 17). Retrieved from https://www.todayshospitalist.com/To-prevent-ordering-errors-one-hospital-is-bringing-read-backs-to-the-bedside/
• Working to reduce medication errors. (2019, August 23). Retrieved from https://www.fda.gov/drugs/drug-information-consumers/working-reduce-medication-errors

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