Tips for Avoiding Medication Errors

To avoid medication errors, you have to find a way to mentally block the distractions and focus on the task at hand. Nurses Nurse Beth Article

Tips for Avoiding Medication Errors

Hi Nurse Beth, I got my nursing license in June and I have worked in a skilled nursing/rehab facility for the past 2 months. Up until 2 weeks ago I was on orientation. The past two weeks, in which I have been on my own, things have been rough. I have had a workload of 25 patients per shift on a skilled nursing floor. And, I've already made 2 medication errors. I'm worried that if keep making medication errors I'll lose my job. Is it common for new grads to make errors like this?

It's very hard to avoid errors considering how I'm always 20 steps ahead of what I'm doing. I have trouble focusing on what I'm doing at the present moment (such as giving medications) because I'm always thinking about what's coming next.

What are your suggestions to avoiding medication errors? What steps should I take to ensure every med pass is safe and effective?

Dear Wants to be Safe,

First of all, can I say having 25 patients is an unsafe workload. Heavier workloads are associated with medication errors. Unfortunately, it's all too common in subacute settings and creates an incredible amount of stress and risk for nurses like yourself who want to do a good job.

Here are some suggestions to help avoid med errors:

Focus

To avoid medication errors, you do have to find a way to mentally block the distractions and focus on the task at hand. A high number of interruptions interferes with nurses' cognitive function (as you know!) and this fact is not always appreciated by administrators.

Some facilities have adopted strategies to help nurses avoid distraction during med pass, including red tape "Silence" zones at the Pyxis/Omnicell, "Do Not Disturb" vests worn by nurses during med pass, with varying results.

STOP and THINK.

  • Be present.
  • Does the dose seem reasonable?
  • Is the medication appropriate for that patient?
  • What is the indication for the medication?

If you are uncertain about any aspect of the medication order, follow your instinct. Stop and check with another nurse.

Follow Procedure

  • Pay attention to Pharmacy cautionary labels such as "Do Not Crush"
  • When giving IV piggybacks, double check to see if the rollerball is released
  • Follow your facility's procedure on independent double checks
  • Use an oral syringe to administer oral or NG meds
  • Follow your facility's "Do not use" abbreviation list
  • Assess patient for allergies before administering medications
  • Familiarize yourself with look-alike, sound-alike medications and your facility's list of high alert drugs
  • Verify patient identity with 2 facility approved patient identifiers
  • Verbal orders for medications should be avoided and reserved for emergencies
  • Repeat back the medication order to the provider when taking a telephone order
  • Avoid removing drugs from packaging until immediately before administration Document administration immediately after administering
  • If a patient objects to or questions the medication you are administering, stop and double check the order

Avoid Variance

Medication administration is a complex process with multiple steps.

When administering medications, follow the exact same steps every time. Like an airline pilot doing preflight safety checks. No shortcuts. No workarounds. Errors are reduced when variability is reduced.

  • Right Patient
  • Right Drug
  • Right Dose
  • Right Route
  • Right Time (yes, some organizations and facilities have added a sixth, seventh and even eighth right, but that's another post)

Reflection

Identify the causes of your errors to prevent the same error in the future. Did you vary from the procedure, or take a shortcut? Use a workaround? Were the 5 Rights followed? Did you miss something because you were rushed?

Environment

The environment you work in influences patient safety. Better environment means fewer medication errors.

The Institute for Safe Medication Practice (ISMP) has released a tool of top medication practices for hospitals to adopt.

People are fallible. Hospitals with a "just culture" encourage nurses to report errors and near misses without fear of reprisal. It's about an atmosphere where staff are expected to be accountable, but risks are openly discussed with management, and there is open communication.

If you decide that the setting you are working in is not conducive to safe medication administration, you may need to re-evaluate your job. I understand not everyone has the luxury of picking and choosing jobs in this market, but when your workload is as heavy as you describe, there is a tendency to take shortcuts, and eventually, a serious mistake could happen.

Best to you and thank you for writing in.

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Nurse Beth

About Nurse Beth, MSN

Career Columnist / Author

Nurse Beth is an Educator, Writer, Blogger and Subject Matter Expert who blogs about nursing career advice at http://nursecode.com

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Specializes in BSN, RN, CVRN-BC.

First, you need to make sure that you are following your facility's medication administration policies.  This should include safe practices to reduce the risk of medication errors.

Second you need better focus.  When you are administering medications you need to be focused and in the moment.  There are methods for improving momentariness such as meditation.  Most cultures practice a form of meditation so if you have an aversion to eastern practice there are many other methods.  One example is prayer done in an extended and structured manner.  As an example, Catholics "pray the rosary."  Most people might not think of this as meditation, but it is an exercise that develops mental focus.  Don't expect to develop Dali Lama like focus out of 15 minutes a day, but a good 20-30 minutes of meditation a day may great improve your ability to focus on the task at hand.  

Third, don't allow yourself to be rushed during medication administration.  If you are falling behind, medication administration is a horrible area in which to cut corners.  You are a new grad.  No one expects you to be able to keep up with the veteran nurses until you have a year or two of experience under your belt. 

Good luck!

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Specializes in Parish Nursing.

I sympathize with this nurse.  Beth sure contributed some great thoughts.  I would add another thought to the first rule of the "Right Patient".  In LTC people are appropriately treated like being at "home" and not in a "facility".  But that comes at a price to the first rule of "Right Patient".  In most LTC facilities, they don't wear ID bands, like in a hospital.  The nurses are usually dependent upon a system like a picture to ID the "Right Patient".  About 10% of the time, I have found that pictures were sometimes not taken or not updated enough for realistic identification .  And if you floated between wings, you could end up with 30+ patients you've never met and a huge challenge for identification.  I found the following helpful (1) CNAs were awesome help in verifying ID, although they were very busy, being courteous to them reaps courtesy and help in return.  (2) Discussed the ID issue with my DON who updated camera supplies to make pictures easier to get accomplished.  (3)  When in doubt, care for the patients you can ID and come back to those you need assistance with.    I sympathize with fellow nurses facing these challenges.  I have seen many break down in tears over the incredible stress of a highly complex and populous med pass.  Be nice to yourself in the learning process and realize that it takes time and you'll get better and faster at it. 

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I think it is not possible to come up with a plan of correcting the med errors without knowing WHY the errors happened.  Are the MARs difficult to understand?  Are you getting too many interruptions?  Are meds missing from your med cart?  Do you need to slow down and concentrate more?

If you are struggling to get your meds administered in the 2 hour window, consider looking into staggering your residents' med times.  For example, instead of having ALL AM meds due at 9am, schedule some for 7, some for 8 and some for 9.  It gives you a little more time to administer everyone's meds and stay in compliance.

A workload of 25 residents is typical of SNF nursing and can be done safely, depending on the shift, what type of support you have (charge nurse to cover orders/labs/etc., decent CNA ratios, separate treatment nurse) and the acuity of the residents.

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I always get confused between Furosemide and Famotidine. Reading the tips provided are very helpful, thank you for the write.

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Specializes in TCU, Dementia care, nurse manager.

Staffing.  More nurses.  Especially! in LTC.  I've been there.  It's sick.  And in LTC, the management wants these to be more "home" style. 

Yeah, crushing meds and taking the time to help dementia and early dementia residents to take their meds - especially crushed: try tylenol, senna for taste, and the K tablets that can't be crushed but can be dissolved in water, tastes great too! - takes a long time.  A long time.  20-25 residents is not uncommon.  Even for a full shift TMA.  Do the math for multiple doses per shift.  And, try the Q2hr parkinson's meds.  And a nurse not only passing meds but dealing with falls, acute changes, fights, feeding those who can't feed themselves, talking with unhappy family (sometimes fair, sometimes absurd).

This 'home' style means no hand sanitizer by the door, either inside or outside.  Or, who knows where the last aide or nurse or resident left the bottle of hand sanitizer.  How about when there is not enough hand sanitizer stocked on the floor?

Something needs to change in TCU, LTC, memory care.

Thanks to the Infinite One who gives the floor excellent management.  Thanks to some of my managers who understood and cared about both the staff and the residents.  The residents might not always get great care, but they never get great care with the staffing and management the way it often is.

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This nurse  needs more support,  teamwork is key.

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
On 3/14/2021 at 4:31 PM, Nurse Beth said:

And, I've already made 2 medication errors. I'm worried that if keep making medication errors I'll lose my job. Is it common for new grads to make errors like this?

Without identifying what errors you made, it's difficult to know if errors "like this" are common. Was a medication missed? A wrong dose administered? An incorrect medication administered? Many variables are in play with medications, although as others have pointed out, it always comes back to the five rights. 

I started my career in LTC with 30 residents on my assignment. I had two med passes on the evening shift, a 4-7pm and 8-10pm med pass, plus a treatment pass for wounds and other issues. It's a challenging workload, but it's normal for long term care, and you can do it safely.

As others have mentioned, focus and attention to detail are key, especially when you're newer. Other staff, patients, family members, etc. are going to come up and potentially distract you. Some facilities have a small sign that says "Please don't disturb nurse completing medication pass". While there are SOME things that require your attention as the nurse, you have to try not to get distracted with things that can be done by others. It took me a while to get comfortable telling patients I couldn't get them another drink right at that moment, or I couldn't get them to the bathroom by myself. Yes, you can do many of the tasks that other staff can do, but they can't do all of yours. So take the time that you need to focus and get things right.

Give yourself a break. You're new and mistakes happen. It will get better. Being in LTC, you will develop some great time management skills and develop some great patient relationships. Good luck!

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I've mentioned this before but the LTC facility I worked at suggested I carry the portable phone on my med cart with me to field calls as I did my med pass. That didn't sound like a good plan ? but it just goes to show you what  management's priorities were. 

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Specializes in RN BN PG Dip.

This list of checks you have to make to ensure you are able to practice safely means you would take too long to give out the medication. Sadly.

The environment for you may not be safe. You have already made two errors. The worry of making another will create too much stress.

In LTC environments the RN is constantly interrupted.  It is hard to focus and manage medications safely.

You could find a safer environment or always do the basic checks right  time - date - patient - drug - dose at the bedside. 

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Specializes in Peds.

I just saw a post where the medication in the bottle was different in the one in the bottle.

The nurse was reported to the board because even though the bottle is labelled"clonidine" the bottle contained Trazadone.

Do we now have to identify the pills in the bottle or bingo cards are the correct pills,even if they come directly from the pharmacy?

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4 hours ago, Runsoncoffee99 said:

I just saw a post where the medication in the bottle was different in the one in the bottle.

The nurse was reported to the board because even though the bottle is labelled"clonidine" the bottle contained Trazadone.

Do we now have to identify the pills in the bottle or bingo cards are the correct pills,even if they come directly from the pharmacy?

Before I even went to nursing school, one time I noticed that my husband's medication looked different as I was picking it up at the pharmacy window.  I inquired with the person who gave me the bottle.  They came back with a correctly labeled bottle of the correct medicine and thanked me profusely for noticing.  Since then, I have become aware of the pill/table identification aid photos one can find on the internet, as well as the word descriptions printed on the bottles.  I think the nurse should be responsible for identifying the medication, but I would give a second thought to reporting her to the board for the mistake.  Medication identification should be made a necessary check when the med is first introduced to the cart.  If anything, the nurse who initially places that med on the cart should be held more responsible for errors of this nature.

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