No More Fatal Doses: Changing Medication Administration to Reduce Deadly Errors

No More Fatal Doses: Changing Medication Administration to Reduce Deadly Errors

Each time medicine is administered incorrectly, the odds of a patient being harmed – or even killed – skyrocket.

New research suggests that some nursing students are not getting the preparation they need to carry out safe medication practices. Obviously, this is not good. American hospitals administer millions of doses of medication every month. Even if errors in medication administration occur during a small fraction of interactions, a tremendous number of patients will be harmed.

Sadly, such medical errors occur all the time. They comprise a large percentage of the 250,000 to 440,000 deaths that result from medical errors in American hospitals each year.

As bad and high as that figure is, it does not even include the number of patients who survive a medical error. For those who suffer non-fatal medical errors, the fallout ranges from mild allergic reaction to lifelong pain, disability, paralysis, or disfigurement. Even “minor” errors often increase the length of hospital stay for patients – they may also result in loss of work and burden family members with difficult duties. And what’s maybe so hard to accept about this is that every medical error – and its ensuing harm – is completely preventable.

The World Health Organization (WHO) estimates that the global cost associated with medication-related errors is around $42 Billion annually. Sometimes, medical errors are not detected and recognized as such, leading many experts to believe the true damage is higher still.

What Is a Medication Administration Error?

The easiest way to think about errors of administration is to think of the “5 rights,” which almost all hospital professionals check before administering any medication to a patient:

  1. The right patient
  2. The right drug
  3. The right time
  4. The right dose
  5. The right route

If any one of these is wrong, then an error has occurred, and the results can be devastating. The Food and Drug Administration (FDA) reported a case where 1 patient was given a blood-thinner that was supposed to go to someone else. That patient developed a hemorrhage and died as a result.

Despite deliberate attempts at reform, errors of medication administration continue to plague hospitals. The frequency of these errors varies from study to study, but their widespread occurrence is not disputed. The real question is: Why is it so hard to administer medicine correctly?

Delving into this question, a team of researchers from the Mennonite College of Nursing (MCN) at Illinois State University wanted to know how often nursing students practice administering medication in a clinical setting. They found a range of policies across institutions, with some students not given the chance to practice at all. At many institutions, there is literally no standard of training when it comes to this crucial nursing responsibility.

More Practice Will Save Lives

Dr. Melissa Jarvill, 1 of the lead researchers at MCN, thinks the answer is more time spent practicing in a simulated clinical setting. She runs the MCN Nursing Simulation Lab, where students practice important administration techniques and protocols under the eye of instructors. Additionally, through observation, Jarvill believes the research will shed some light onto why nurses make errors in the first place. “We try to see it from their perspective,” said Jarvill.

“Why did they do what they did? For example, if the nursing student hesitates to call a doctor, why? Is it because they are unsure of their role as a nurse? Do they feel like they can’t question the doctor’s order?”

Ideally, insight gained from these low-stakes scenarios will continue to improve training that can save real lives.

A Long Road Ahead

While it is important to focus on what is happening at the point-of-care, research also suggests that it is the circumstances under which the nurse is working or the organizational issues within the hospital that play a major role in creating a medical error. The reality is that medication administration errors can happen during any phase of the medication process, such as procuring, dispensing, or monitoring.

For example, the FDA reported an instance where a pharmacist prepared 260 milligrams of Taxotere for a patient instead of Taxol. These chemotherapy drugs are used to treat different types of cancer, and the mix-up cost the patient their life. The most shocking thing about that case is the death was not classified as an “error” because the patient had been so sick already.

Clearly, the status quo is not good enough. As a patient, one can try to be alert and informed, but at the end of the day, it is the hospital’s responsibility to see that the proper medications are administered safely. As more families are crippled by preventable errors, there is an obvious opportunity to improve in this regard. Hopefully hospitals see it this way, too.

Sokolove Law Team

Contributing Authors

The Sokolove Law Content Team is made up of writers, editors, and journalists. We work with case managers and attorneys to keep site information up to date and accurate. Our site has a wealth of resources available for victims of wrongdoing and their families.

Last modified: May 20, 2019