June 14, 2008

Errors in Medicine Administration: How Can They Be Minimised?

By Venkatraman, Ramya Durai, Rajaraman

KEYWORDS Electronic prescribing / Error / Medicine administration / Patient safety / Safety Errors in medicine administration often go unnoticed and unreported. This article describes three medicine- related errors and provides recommendations to reduce risk. All medicine-related errors should be reported locally and to the National Patient Safety Agency (NPSA) so that they can be collated and trends identified. Electronic prescribing and patient/medicine identification by bar codes, double checking and using colour coded syringes for intravenous and enteral administration, employing more clinical pharmacists and regular education may reduce medicine- related errors.


Errors in medicine administration can be lethal (McKeown 2007). The wrong route of administration is sometimes repeated because of human error (Bell 2007) and is frequently a problem in neonates receiving parenteral nutrition (Bridge 2007, Steckmeyer et al 2007). Other than the neonates, two more potential areas where medicine- related errors occur frequently are patients receiving chemotherapy (Diaz-Carrasco et al 2007) and confused elderly patients who are receiving more than five medicines (Fernandez Lison et al 2006). Prescription error is known to be the most common cause of medicine- related error (Knudsen et al 2007).

The route of administration and dosage of medicines are of vital importance. Many medicine errors go unnoticed and unreported because only a few of them have serious consequences. When administering medicines, nurses usually double check the patient name, the medicine name, the dosage of medicines, the route of administration and frequency with their colleagues and document on the prescription chart. This may avoid mistakes related to relevant medications. Doctors are not routinely trained to administer medicines. Nurses sometimes ask the junior doctors to administer medicines in certain situations. On these occasions, only a few doctors double check the medicines before they administer them. Common causes of errors in medicine administration include:

* inattention

* haste

* medicine labelling error

* communication failure

* fatigue (Abeysekera et al 2005).

Wrong medicines, overdosage and the incorrect route of administration remain unsolved problems (lrita et al 2004) in clinical practice. This article aims to raise the awareness of medicine-related errors among medical and nursing staff. This short report describes three medicinerelated adverse events and suggests possible solutions to minimise the risk. The first was due to an error in the route of administration, the second describes a dosage error and third relates to the frequency of administration.


The Department of Health's document An Organisation with a Memory (DH 2000) reports that 850,000 adverse events may occur each year in the NHS costing more than Pounds 2bn. Many adverse events are often repeated. The report provides key solutions for minimising the problem which are summarised in Table 1.

Medicine-related adverse events occur frequently and can sometimes be fatal. To reduce the risk of error, medicines should be prepared for only one patient at a time (NMC 2007). Intravenous (IV) medicines should not be prepared at the same time as medicines to be administered via other routes (for example, nasogastric (NG), oral or intrathecal). All medicines whether they are administered via NG or IV should always be clearly labelled with the patient's details including name of the medicine, the dose and the route of administration to avoid confusion. To reduce errors, high risk medicines should be checked with a second qualified person and signed on the prescription chart. This second person should check that it is the correct medicine, the correct dose, the correct frequency, the correct route of administration and the correct patient.

Table 1 Medicine-related error: possible causes and suggested remedies

Staff administering medicines should record adverse events and near misses by completing the appropriate incident form. The incident will be graded by the clinical manager and an investigation will be undertaken and an action plan introduced for all events (where needed). It is considered best practice for staff to make a contemporaneous diary note or a statement of the events surrounding the adverse event. Reflecting on the event will reduce the possibility of it re-occurring. A copy of the statement may be stored in their portfolio. Individual staff must undergo competency- based assessment at regular intervals (for example, every two years).

Junior doctors should undergo training in preparing and administering medicines during their initial years of training and it should form part of their ongoing assessments. Medical wards and intensive care units are common areas where medicine-related errors occur often (Tang et al 2007). The two most common errors are the wrong dose and the wrong medicine. Antibiotics are the most common erroneously administered medicine (Tang et al 2007). Medication errors can be minimised by double checking medications, crew resource management, computerised entry, incident reporting and root cause analysis (Tamuz & Harrison 2006).

Table 2 outlines some of the possible causes and suggested remedies related to medication related adverse events. In the authors' opinion, medicine errors are unavoidable but they can be minimised by regular staff training. We recommend that the British National Formulary (BNF) or an electronic compendium (for example, medicines.org.uk) should be accessible in every clinical area and it should be referred to regularly to avoid any mistakes. The on-call pharmacist provides 24 hour coverage in every hospital and should be contacted when there is any doubt about a medicine or when adverse events occur.

If there is an error in medicine administration, an incident form should always be completed and the regional poison centre may be contacted for advice if appropriate. The patient should be examined and monitored carefully. The General Medical Council (GMC), which regulates the medical profession in the UK, recommends openness and honesty. Therefore patients should be informed about any adverse events or near misses which may affect them. The NPSA was set up to reduce the number of incidents and errors in the NHS. Every individual and each NHS trust should ensure that medicine-related adverse events are reported so that others can learn to avoid these errors. Open and fair reporting culture will result in a safer NHS.

A Spoonful of Sugar (Audit Commission 2001) discussed medicine management in NHS hospitals. The Audit Commission suggests:

* Induction and training of junior doctors regarding medication prescribing and error reporting.

* A focus on near misses to avoid repetition.

* The use of computer technology for avoiding errors from illegible prescribing.

* The integration of clinical pharmacists into clinical teams.

Medication Safety Initiative is a new approach for raising awareness and minimising medicine-related errors. The Washington Patient Safety Coalition (www.wapatientsafety.org) provides recommendations for minimising errors.

Table 2 Recommendations from An Organisation with a Memory (DH 2000)*

These include:

* Avoiding the use of unsafe abbreviations.

* Reducing polypharmacy.

* Periodic medication reviews.

* Inclusion of the indication for all medications.

* Reading out the prescription and explaining the need to patients.

The Nursing and Midwifery Council (NMC) has recently published updated guidelines on medicines management (NMC 2007). It recommends that nurses double check medications that require complex calculations - this is applicable to injections and controlled drugs. The only exemption to this rule is medical emergencies when a doctor administers drugs. The nurse who is in charge of the patient should make sure that doctor follows the checks correctly.

Medicine-related errors are also common in neonatal ICUs and the NPSA is leading a two-year initiative to improve neonatal patient safety from 2007-9 (NSPA 2007). Under-dosing is common and computer aided dosing calculation may reduce dosing errors (Kirk et al 2005). Double checking all medicines has been shown to reduce errors (Ross et al 2000). Some paediatric doctors often make mistakes in calculating the dose of medications (Rowe et al 1998). Those with poor mathematical skills should be identified and competency assessed. Calculators and computers should be used to check calculations.

Electronic prescription systems ('e-prescribing') are a new concept that may help to avoid administering wrong medicines and wrong doses (Ampt & Westbrook 2007). Apart from e-prescription, automated dispensing and identification of patient/medicines by bar code are also known to reduce medicine-related errors (Franklin et al 2007). E-prescribing requires proper planning and monitoring to minimise the risk of adverse events (Giurdanella & Di Denia 2007). Personal digital assistants (PDAs) can be used to supplement e- prescribing and for improving medicine-related knowledge (Greenfield 2007). With e-prescribing, the dose related error and allergic medicines can be avoided (Jayawardena et al 2007). Pharmacists are essential as they can locate and correct prescribing errors (Krahenbuhl-Melcher et al 2007). Anonymous reporting of errors helps to reduce repetition (Lehmann et al 2007). Computerised prescriptions have also been shown to reduce outpatient prescription errors (Varkey et al 2007). In Case 1, the incident could have been avoided by using a display near the patient's bedside instructing staff to check the route of administration because the patient has both NG tube and IV access. The NPSA advocates the use of colour coding of syringes for medicines for administration by different routes together with clear labelling (NSPA 2007). Also during the nursing handover, colleagues should have been reminded about the potential risk.

In Case 2, if the registrant had adhered to the accepted and agreed standards for intravenous medicines administration (by labelling all medication and double checking the details with the registrant who administered the medicine) this event could have been avoided.

In Case 3, the mistake can be prevented by reinforcing to staff that best practice is to not only check that the right medicine has been selected but that the dose and frequency (and maximum 24 hour dose) is correct before administration.


Errors in medicine administration can be minimised by applying a systematic approach to administration. Safe administration requires that the correct patient is identified against the prescription (noting allergies and sensitivities), checking the dose with BNF or a pharmacist when there is any doubt, double checking the medications with another qualified staff member together with regular education of staff about the importance of reporting all near misses and adverse events.

Provenance and Peer review: Unsolicited submission; Peer reviewed.

Case 1 Route of administration error

A 16 year-old boy presented with polytrauma including a pelvic fracture. He was initially admitted to the Intensive Care Unit (ICU) with a head injury. Once his condition was stable, he was transferred to the orthopaedic ward during the early morning. There he was fed via a nasogastric tube and also had intravenous access for fluid/medicine administration. The patient was well and alert. In the evening he suddenly complained of a burning sensation all over the body, his respiratory rate increased to 36 breaths per minute - although the saturation and blood pressure were 96% and 120/ 70mmHg respectively - his pulse rate was 140 beats per e minute. The patient was very agitated, irritable and was very difficult to calm. His I blood tests including a full blood count, urea and creatinine were within the normal range. His electrocardiograph showed a sinus tachycardia. Arterial blood gases were within normal limits. Intravenous morphine and supplemental oxygen did not improve his clinical condition. It was initially thought that he had sepsis although there were no physical signs.

At this point the nurse who looked after this young boy during the day shift informed the ward (by telephone from home) saying that she had given soluble paracetamol (1 gram) intravenously by error instead of the nasogastric route. The patient was monitored serially for any deterioration in his condition and the local poison centre was consulted. Fortunately, his symptoms settled after a few hours without any intervention. The incident was reported via critical incident reporting to the relevant authorities.


The temporary (bank) staff member was tired. The registrant was unfamiliar with medicines handling and administration. The patient and family were informed fully about the incident, and the bank staff member was cautioned. A decision was made to ensure that all qualified bank staff had undertaken appropriate medicines management training and were competent to administer medicines within that clinical setting.

Case 2 Dosage error

A ventilated 27 week-old premature baby suddenly deteriorated. On examination the baby was found to be inadequately sedated and was trying to take breaths against the ventilator. The ventilator was set to volume control rather than pressure control. The physician planned to administer pancuronium 0.1 mg/kg (for paralysis) and a morphine bolus (for analgosedation). The neonate was already receiving a continuous intravenous morphine infusion. The nurse, who was looking after the baby, prepared both the medicines and a sodium chloride 0.9% flush. All medicines were prepared in 2ml syringes without labels. The nurse in charge accidentally administered 10 times the required dose of pancuronium. The neonate was examined immediately and vital parameters were monitored vigilantly. An incident report form was completed and the consultant was informed. After 24 hours the neonate's condition returned to its pre-incident state and stayed stable on the ventilator.


Under stress, the nurse did not label the medications, even though she had completed an IV study day. All nurses and non- nursing qualified staff should receive training and complete competencies before administering any medicines by any route. Wherever possible two registered staff should check medicines for intravenous administration - one of whom should also be the registrant who administers the medication (NMC 2007). After this incident, the nurse was cautioned. The nurse and her colleague who countersigned the CD register had to undergo further training on IV medicine administration and successfully complete their drug administration competency (administration under supervision) and medicine calculations before they were allowed to administer medicines without supervision.

Case 3 Error in frequency of administration

A 30 year-old female, who underwent fixation of a fractured toe with a K-wire, vomited twice in the postoperative period. She had received two doses of cyclizine 50mg at eight hour intervals as recommended in the Special Product Characteristics (SPC) (www.medicines.org.uk). The nurse on the night shift gave a third dose of cyclizine, one hour after the second dose, without looking at the time of the previous dose. The night nurse contacted the doctor for an alternate anti-emetic because the symptoms were not settling. Cyclizine is an antihistamine which is effective for nausea, but less effective for vomiting (Royston & Cox 2003). It can produce anticholinergic side effects, dysphoria and but most frequently sedation (Kovac 2000). Physical examination of the patient was essentially normal and it was concluded that she was sensitive to emetic effects of morphine. An alternative antiemetic was administered and her symptoms settled. The incident was reported to the appropriate authorities.


Even though the staff member was fully trained, tiredness and stress caused her to make an error. The staff member was cautioned.

If there is an error in medicine administration, an incident form should always be completed

Errors con be minimised by applying a systematic approach to administration


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by Ramya Venkatraman and Rajaraman Durai

Correspondence address: Mr R Durai, Department of Surgery, Queen Mary's Hospital, Sldcup, DA14 6LT. Email: [email protected]

About the authors

Ramya Venkatraman


Specialist Registrar In Paediatrics,

The Royal London Hospital, London

Rajaraman Durai


Specialist Registrar in General Surgery,

Queen Mary's Hospital, Sidcup

Copyright Association for Perioperative Practice Jun 2008

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