MEDICATION ERRORS

Mahmood Ahmed
Introduction of Medication errors:
Medication Errors:
Medication errors can be defined as any occurrence that can cause a patient to receive the wrong dose, the
wrong drug, an incorrect dosage of the drug, a drug by the wrong route, or a drug given at the incorrect time.
Errors may occur in transcribing drug orders, when the drug is dispensed, or in administration of the drug.
Any deviation from the rules and regulations, and methods, prescribed for drugs Medication management
requires the collaborative efforts of many health care providers. Medication may be prescribed by a
Physician, dentist, or other authorized prescriber such as advanced practice registered nurse as determined
by the individual state licensing bodies. Pharmacists are licensed to prepare and dispense medications.
Nurses are responsible for administrating of medications. Dieticians are often involved in identifying
possible food and drug interactions. Medication administration requires specialized knowledge, and nursing
skills based on the principles of pharmacology.
Classification of medication errors:
Decision errors
Documentation errors
Dispensing errors
Decision Administration errors
Technical errors
Was the order correct in light of the available information?
Was the relevant information available to the physician?
Was the order communicated completely, timely and unchanged to the nurse in- charge of
dispensing?
Was the drug dispensed as ordered?
Was the correct drug given to the correct patient at the correct time?
Was the drug given in the correct way and errors involves equipments such as infusion pumps
Self medication
Where errors occur?
In hospital
In community
Distribution of Medication Errors According To Occurrence:
Types of medication errors
Decision
Documentation

Number of events
39
64

Percentage events
18%
29%

Dispensing
Administration
Technical
Classes not applicable
Total number of events
Drugs standards and Legislation:

47
41
30
13
211

21%
19%
14%
-

A drug is a chemical substance intended to elicit a specific effect. An assumption made by the nurse before
administration of any medication is that the drug will be safe for the client to consume if the dose,
frequency, and route are within the therapeutic range for that drug. This assumption is implied in accord with
standards that are set to ensure drug uniformity in strength, purity, efficacy, safety, and bioavailability.
Standards:
Standards have been developed to ensure drug uniformity so that effects are predictable The United States
pharmacopoeia and the national formulary are books of drug standards for use in the US. The TJSP and NF
list drugs that have been recognized as being in compliance with legal standards of purity, quality, and
strength.
Legislations:
In USA the Pure Food and Drug Act was designated the USP and the NF as official bodies to establish drug
standards. It also gave the federal government the authority to enforce these standards .The federal Food and
Drug and Cosmetic act of 1938 empowered the Food and Drug Administration (FDA) to test all new drugs
for toxicity before granting the pharmaceutical company the approval to market a drug. The federal Food
Drug and Cosmetic Act of 1938 was amended in 1952 to distinguish prescription (legend ) drug from non
prescription (over the counter) drugs and to regulate the dispensing of prescriptions Testing for drug
effectiveness materialized with the Kefauver-Harris Act of 1962.
The Harrison Narcotic Act of 1914 classified habit forming drugs as narcotics and began regulating these
substances. The Controlled substance Act of 1970 defines a drug dependent person in terms of physical and
psychological dependence and provides for strict regulation of narcotics and other controlled drugs such as
barbiturates through the establishment of drugs schedule.
Drug nomenclature:
A drug may be used as an aid in the diagnosis, treatment and prevention of disease or under other conditions
for the relief of pain or suffering or to improve any physiologic or pathological condition. The terms drug,
medication medicine are often used interchangeably by health care providers and laypersons.
Drugs can be identified by their chemical, generic, official or trade name the chemical name is a precise
description of the drugs composition (chemical formula).The nonproprietary or generic name in the United
States Adopted Names Council to the manufacturer who first develops the drug. When the drug is approved
it is given an official name. When pharmaceutical companies market the drug they assign a proprietary name
called a trade (brand) name. Therefore one generic drug may have several trade names based on the number
of companies marketing the drug For example, ibuprofen is a generic name but common trade names for this
drug are Advil, Mortin, Nuprin and Brufen .Generic names are not capitalized, but trade names are always
capitalized.

Pharmacology:
Pharmacology is the study of the effects of drugs on living organisms. Pharmacological activities of drug
actions those are related to medication management, drug classification, drug preparation and routes of
administration.
Medication management:
The purpose of medication management is to produce the desired drug action by maintaining a constant drug
level. Drug action is based on the half life of a drug. a drugs half life refers to the time it takes the body to
eliminate half of the blood concentration level of the original drug dose. For example, if a drug has a half
life of 6 hours 50% of drugs original dose is present in the blood 6 hours after administration; in 12 hours
after administration, 25% of the drug is present, because of a drugs half life ,repeated doses are often
required to maintain the drug level over a 24-hour interval.
Other term used to describe drug action: onset, peak plasma level, and plateau. Onset of action is the time it
takes the body to respond to a drug after administration. A peak plasma level is the highest blood
concentration of a single drug dose before the elimination rate equal the rate of absorption. Once the peak
plasma level is achieved, the blood concentration level is steadily unless another drug dose is given. If a
series of scheduled drug is administered; the blood concentration level is maintained; maintenance of a
certain level is called a plateau.
Classification:
Drugs are commonly classified by the body system with which they interact (e.g. cardiovascular) or in
accord with the drugs approved therapeutic usage (e.g. antihypertensive) drugs with multiple therapeutic
uses are classified in accordance with their most common usage.
Preparation and route:
Drugs are available in many forms for administration by a specific route. The route refers to how the drug is
absorbed: oral, buccal, sublingual, rectal, parenteral, topical and respiratory.
Oral Route:
Most drugs are administered by the oral, because it is the safest, most convenient, and least expensive
method. The disadvantage of the oral route is that it acts more slowly than the other routes, such as
injectable. Drugs may not be given orally to clients with gastrointestinal intolerance or that on NPO (nothing
by mouth) status oral administration is also precluded by coma. When small amount of drugs are required
the buccal or sublingual route is used drug administered through these routes act quickly because of the oral
mucosa, s thin epithelium and large vascular system, which the drug to quickly be absorbed by the blood.
Parenteral route:
Parenteral drugs are administered with sterile techniques by injectable routes by definition parenteral route
refers to any route other than the oral gastrointestinal tract; however the medical usage of the term excludes

topical administration. These are four routes that nurses routinely use to administer the parenteral
medication:
Intradermal (ID) is an injection into the dermis.
Subcutaneous (SC or SQ) is an injection into the subcutaneous tissue
Intramuscular (IM) is an injection into the muscle.
Intravenous (IV) an injection into a vein.
Other parenteral routes, such as intrathecal or intraspinal, intracardiac, Intrapleural, intra-arterial and intraarticular are used by physicians and in some cases by advanced practice registered nurses for medication
administration.
Topical route:
Most topical drugs are given to deliver a drug at, or immediately beneath the point of application although a
large number of topical drugs are applied to the skin, other topical drugs include eye nose and throat, ear,
rectal and vaginal preparations. Drugs directly applied to the skin are absorbed through the epidermal layer
into the dermis, where they create local effects or are absorbed into the bloodstream. Drug action varies with
the vascularity of the skin, usually requiring several applications over a 24-hours period to cause the desired
therapeutic effects. Transdermal patches another type of topical preparation are used to deliver medications
such as nitroglycerine (Transdermal-NTG), an antianginal and certain supplemental hormone replacements
for absorption by the blood to produce systemic effects. Some topical drugs such as eye and nasal drops and
vaginal and rectal suppositories, can be applied directly to the mucous membranes. These drugs are absorbed
quickly into the bloodstream, and, depending on the drugs dose (strength and quantity), my cause systemic
effects.
Inhalants:
Inhalants such as oxygen and most general anesthetics deliver gaseous or volatile substances that are almost
immediately absorbed into the systemic circulation. The inhalants are delivered into the alveoli of the lungs,
which promote fast absorption due to:
Permeability of the alveolar and vascular epithelium
Abundant blood flow
Very large surface area for absorption
Oropharyngeal hand-held inhalers deliver topical drugs o the respiratory tract to create local and systemic
effects. There are three types of inhalers: the metered dose inhaler, or nebulizer; the turbo-inhaler; and the
nasal inhaler. They explained later in this chapter.
Pharmacokinetics:
Pharmacokinetics refers to the study of the absorption, distribution, and excretion of drugs to determine the
relationship between the dose of a drug and the drugs concentration in biological fluids. The knowledge of
pharmacokinetics is used by health care providers in medication management. The physician, when ordering
a drug, is concerned mainly with determining the dose and route that will produce the most therapeutic
effects; physicians, pharmacists; physicians, pharmacists and nurses are all involved in identifying

appropriate times for drug administration and for avoiding interactions with other substances that could alter
the drugs actions. Drug actions are dependent on four properties: absorption, distribution, metabolism and
excretion.
Absorption:
The degree or rate of absorption or passage of a drug from the site of administration into the bloodstream
depends on several factors; the drugs physicochemical effects its dosage form, its route of administration,
its interaction with other substances in the digestive system and various client characteristics such as age.
Oral preparations such as tablets and capsules must first integrate into smaller particles for gastric juices to
dissolve and prepare the drug for absorption in the small intestines.
Drugs administered intramuscularly are absorbed through the muscle into the bloodstream. Suppositories are
absorbed through the mucous membranes into the blood intravenous drugs are immediately bioavailability
because of their direct injection into the blood.
Distribution:
Distribution refers to the movement of drugs from the blood into various body fluids and tissues. The degree
of binding between blood proteins and chemical substances can limit the drugs distribution in the body the
actual volume of distribution of any drug can be altered by the clients health condition.
Metabolism:
Metabolism refers to the physical and chemical processing of a drug, by the body. Most drugs are
metabolized in the liver the rate of metabolism is determined by the presence of enzymes in the liver cells
that detoxify the drugs. Certain drugs can also increase the rate of metabolism.
Excretion:
Excretion is the elimination of drugs from the body. This occurs mainly through hepatic metabolism and
renal excretion. Other organs such as the lungs, exocrine glands skin and intestinal tract can eliminate some
drugs. Drug interaction:
Drug interaction refers to the effects; one drug can have on another drug. Drug interaction may occur when
one drug is administered in combination with a second drug or a short time interval exists between the
administrations of two different drugs. Drugs can be combined deliberately to produce a positive effect; for
example, hydrochlorothiazide a potassium depleting diuretic and spironolactone (Aldactone) a potassium
sparing diuretic can be combined to maintain a normal blood level of potassium a positive drug combination
can also occur when one drug is deliberately given to potentiate the action of another drug, as in
preoperative medications. Not all drug combinations are therapeutic. Some drugs combinations can interfere
with the absorption effect, or excretion of other drugs for example calcium products and magnesium
containing antacids can cause inadequate absorption of tetracycline, an antibiotic in the digestive tract.
Food and drug inter action:
Medication management requires avoidance of possible food and drug interactions. There are three primary
types of food and drug interactions:

 Certain drugs may interfere with the absorption, excretion or use in the body of one or more nutrients
Certain foods may increase or decrease the absorption of a drug into the body
Other foods may alter the chemical actions of the drugs preventing their therapeutic effects on the body
Factors influencing drug action:
Individual client characteristics such as genetic factors, age height and weight, physical and mental
conditions can influence the action of drugs on the body. Sometimes mistaken for drug allergies genetic
factors can interfere with drug metabolism and produce an abnormal sensitivity to certain drugs.
The physician often correlates the clients age, height and weight when determining the dosage for many
drugs the nurse should make sure that this information is accurately recorded in the clients medical record.
The amount of body fat may also alter drug distribution because some drugs such as Digoxin an Inotropic
drug, are poorly distributed to fatty tissues.
Medication order:
In health care settings, the medication orders are written on a physicians order form in each clients medical
record. The drug order form is stamped with the clients name room number age and weight.
All orders should be written clearly and legibly, and the drug order should contain seven parts.
The name of the client
The date and time when the order is written
The name of the drug to be administered.
The dosage.
The route by which it is to be administered
The time of administration and frequency. 7 the signature of the person writing the order e.g physician
Types of orders:
Medications are prescribed in different ways depending on the purpose medication can be prescribed as stat,,
single dose ,scheduled ,and PRN orders
Stat orders:
Those orders that should be administered immediately. not an hour or two later
Single dose orders
These are one time medications. The drug is administered either at a time specified by the physician or at the
ear convenient time these drugs are often used in diagnostic and therapeutic procedure
Scheduled orders:
Scheduled orders are administered routinely as specified until the order is cancelled by another order. These
drugs are administered as for a limited or whole the life e.g. antibiotics for a specified time Insulin for the
whole life.
PRN (pro re nata) orders:
Drug prescribed on a PRN (as ended) basis as circumstances indicate. The drug is administered when
clients condition requires it e.g. some pain relieving drugs and sleep inducing drugs Systems of weight and
measurement

Medication administration requires the knowledge of Wight and volume measurement systems. Three
different systems of measurement are used in medication management metric apothecary and household
Metric system:
The metric or decimal system is a simple system of measurement based on units of 10 the basic units can be
multiplied or divided by 10 to form secondary units .the decimal point is moved to the right when changing
from a larger unit, and the decimal points moved to the left when changing from a smaller unit to a larger
unit. For example:
5g

= 5000mg

0.5mg = 500mg

5 mcg = 0.005mg

1.25 L = 1250 mL

0.25

2.45 kg = 2450 g

= 250 mg

Apothecary system
The apothecary system is based on the weight of one grain of weight therefore the basic unit of weight is the
grain (gr) and the basic unit of volume is the minim (the approximate volume of water that weighs a grain).
Important apothecary equivalents and abbreviations are:
Volume
60 minims

1 fluid dram (fl ,dr)

8 fluid drams

I fluid ounce ((fl, oz)

16 fluid ounces

I pint (pt)

weight
60 grains (gr)

I dram (dr)

8 drams

1 ounce (oz)

12 ounce

1 pound (lb)

House hold system:

It is same to the apothecary system of measurement; it is used as a reference standard to help the client.
These units are often used to inform clients of the size of a liquid dose and are generally used in the
calculations of a clients intake and output. Important household equivalents and abbreviations to remember:
Volume (liquid)
60 drops (gtt)

1 teaspoon (tsp)

3 tsp

I tablespoon (Tbsp)

2 Tbsp

I ounce (oz)

S oz

1 cup(c)

2 cup

1 pint (pt)

2 pints

1 quart (qt)

weight
16 ounces

1 pound (Ib)

Drug dose calculations:

Several formulas are used to calculate the drug doses for example:
Volume in ml
Desired dose in a desired time = -----------------------------Time in minute
E.g. you are advised to administer a drip of 1500 ml in 5 hours
Volume in ml
Desired dose in a desired time = -------------------------------Time in minute
1500
Desired dose in a desired time = ----------------- = 5 ml per minute
5 * (60)
Guidelines for medication administration:
To protect from medication errors nurses have traditionally used as a guide lines the FIVE
RIGHTS of drug administration a follows:
Right drug
Right dose
Right client
Right route
Right time
Right documentation
The nurses are legibly responsible for knowing the usual dose, the expected action, and the side effects the
adverse effects and any interaction with other drug or food of every drug administered. Without the
knowledge the nurse should to administer any medication.
Guidelines for safe administration of medication:
Never administer medications that are prepared by another nurse. You are responsible for a medication
error if you administer a medication that was inaccurately prepared by another nurse
Nurse should listen carefully to the client who questions the addition or deletion of a medication. If a
client questions the 4mg or dose you are preparing to administer, recheck the order
If a medication is withheld, indicate the exact reason in the clients record. Legally you are responsible
for giving prescribed medication to the client; however circumstances may prevent you from giving
them and these must be documented
Do not leave the medications at the clients bedside. The client may forget to take the medication,
medication can accumulate, and the client could take two or more of the same medication, causing an
overdose
Advice clients not to take medications belonging to others and not to offer their medications to others.
Medications are ordered for each client on the basis of the history, physical examination and
effectiveness of the medication.

References:
Lois W.(2001). Foundations of Nursing.( 18t Edition). USA. Delmar.
Ellen Thomas B. (1994). Nursing Documentation USA. Lippincott.
Tong B.C. and Phipps W.J. (1985). Medical Surgical Nursing: A Nursing Process Approach. 3rd Edition.
Mosby Boston.