Which situation is most likely to result in the nurse making a medication error?

A few years ago, UCalgary Nursing senior instructor Kathleen Davidson, RN, MN, was developing an article (with fellow nursing instructor Kara Sealock and then-student Wai Yin Mak) about nursing students with ADHD and managing distractions in the workplace.  

“It became apparent to me that all nursing students, to a greater or lesser degree, struggle with distraction in the clinical environment,” Davidson says now. And so began her research to uncover a method to help students hone their selective attention skills for managing in often chaotic clinical situations.

That research has resulted in a recently published open-access article, Adapting a Distraction and Interruption Simulation for Safe Medication Preparation: An International Collaboration, in Clinical Simulation in Nursing, Volume 65, April 2022. 

Nurse distractions and interruptions are leading causes of medication errors in nursing practice, with medication preparation being the most-interrupted activity.

“It is students and novice nurses who are most likely to make a medication error,” explains Davidson, “often because they haven’t honed those selective attention skills.” Interruptions may include self-distraction, events close by, patients, other health-care providers, phone calls and texts. 

Kathleen Davidson, senior instructor, UCalgary Nursing.

“Lots of nursing students believe that distractions and interruptions won’t affect their focus, which can be very dangerous. But we don’t have many evidence-informed strategies for how we can teach maintenance of safety with inevitable distractions,” Davidson says.  

Davidson was intrigued by a simulation created by nursing faculty at Ball State University in Indiana, led by Dr. Cindy Thomas, RN, EdD, in which groups of 10 students entered a lab, put on headphones with a recorded hospital soundtrack at a set volume and completed the preparation of 10 medications.

Faculty and others entered and exited the lab while carrying on conversations and asking the students questions. At the end of the eight-minute simulation, students self-checked the medications they had prepared and discovered they consistently made errors including dosage miscalculations, failing to withhold medications due to patient allergies, or not completing the medication preparation.  

In collaboration with Thomas, Davidson and her UCalgary Nursing team (Carla Ferreira, Pat Morgan and Lorelli Nowell) adapted and piloted the U.S. simulation with 18 Canadian nursing students in 2019.

Some of the changes from the U.S. simulation included two students sharing a medication cart located in a narrow, crowded hallway outside the patient rooms, ambient hospital noise plus overhead announcements, intravenous pumps alarming, patients’ call bells ringing, and interruptions by family members. 

Students experienced their first interruption, from a family member, approximately three minutes into preparing medications. Three minutes later, students were interrupted again by an RN colleague and approximately one minute later, the final interruption was an overhead announcement.

At the conclusion of the simulation, students self-evaluated their prepared medications for accuracy and, in a facilitated debrief, reflected on their experience with the simulation. While never directly asked, some voluntarily spoke about making medication errors and having near-miss events during the simulation.

Students consistently indicated the exercise accurately reflected clinical conditions and allowed them to critique their personal responses to distractions and interruptions. Strategies that students used during the simulation were shared among group members along with ideas for coping with distractions and interruptions in practice.  

Reducing medication errors and improving patient safety are central concerns of the nursing profession on both sides of the Canada-U.S. border and have led to an international research project to discover how this simulation may enable students to develop strategies for maintaining safe medication practices in highly interruptive clinical environments. 

Safely exposing senior nursing students to medication errors and near-miss events through simulation is one way to help address this ongoing issue.

“Reflecting on and refining their personal strategies to maintain focus will hopefully sensitize students/novice nurses about their role in avoiding interrupting their colleagues and the myth of multi-tasking,” says Davidson. 

Medication errors can occur at any time between when a clinician prescribes a medication and a patient receives the drug. If the patient is fortunate, a medication error will have little to no effect on their wellbeing. But if the patient is less fortunate, a medication error can lead to significant harm, even death. As the data shows, this happens much more than it should.

The U.S. Food and Drug Administration states that it receives more than 100,000 U.S. reports annually associated with a suspected medication error. Furthermore, it was estimated that medication errors harm an estimated 1.5 million people annually. Every one of these people has a story to be told about an error that could have been avoided.

Here are six stories about medication errors that received increased media attention.

1. Vecuronium injected instead of Versed

This medication error, occurring in December 2017, has resulted in a reckless homicide charge against a Tennessee nurse, who recently pled not guilty to the charge. As the Associated Press and other news outlets reported, the nurse allegedly injected a 75-year-old patient with the paralytic anesthetic vecuronium instead of Versed, a sedative. The nurse supposedly chose to override safeguards when she could not find Versed in an automatic dispensing cabinet, typed "VE" into the cabinet's system, and then selected the first medication — vecuronium — that came up on the list.

2. Pegfilgtastim administered instead of filgrastim

This medication error took the life of an Air Force veteran and resulted in an $800,000 federal government settlement, according to a report in The State. In early 2017, the patient reportedly went to Dorn VA Medical Center in South Carolina with nausea and vomiting. He was administered doses of pegfilgtastim but should have received filgrastim.

While both medications are administered by syringe and intended to stimulate white blood cell growth, the prescribed filgrastim can be taken daily. Following 11 days at the hospital and multiple doses of pegfilgtastim, the patient died after developing pulmonary toxicity leading to severe acute lung injury.

3. Excessive amounts of Levophed administered

This 2014 medication error at Vibra Hospital of Sacramento (Calif.), a long-term, acute-care facility, claimed a patient's life. The California Department of Public Health (CDPH) also penalized the facility a maximum fine of $75,000.

As The Sacramento Bee reports, referencing a CDPH regulator report, the patient's heart stopped following administration of Levophed, a blood pressure drug. While the medication type was correct, a nurse administered 3,000-8,000 times the prescribed dosage. Numerous factors contributed to this error, regulators determined, including the lack of safeguards for high-alert medications, administering nurse's lack of experience with Levophed, and failure for a second nurse to sign off on dispensing the medication.

4. Tryptophan prescribed instead of baclofen

This medication error cost the life of a Canadian child. According to a report from the ISMP Canada Safety Bulletin, the child had been receiving a prescribed dose of tryptophan at bedtime to treat a sleep disorder for about 18 months. A refill was ordered and filled. The child received the prescribed dose but was found dead in his bed the next day. The post-mortem toxicology test identified the antispasticity agent baclofen at the expected concentration of the prescribed tryptophan. It was determined that the child had received a dose of baclofen more than 20 times the maximum recommended pediatric dose. As ISMP notes, "This finding was consistent with a selection error having been made at the pharmacy, whereby one ingredient was inadvertently substituted for another."

The error and child's death has prompted his mother to push for mandatory reporting of all errors made by Ontario pharmacies.

5. Order for warfarin misplaced

A transcription mistake was the cause of this 2015 medication error that eventually led to the death of a nursing home resident. As McKnight's Long-Term Care News reports, citing information from a Minnesota Department of Health report, a resident at Golden Living with a history of stroke and atrial fibrillation was on long-term therapy with warfarin. A nurse transcribing the resident's warfarin order placed the order in another resident's record. The error went unnoticed. For nine days the resident who should have received the warfarin did not. This resident was hospitalized and later died of a stroke and respiratory failure.

As the McKnight's report notes, the news of the medication error and death came just over a month after a report of another error at a nursing home that led to a resident's death. The cause: administration of 10 times the resident's normal dose of morphine.

6. Navane dispensed instead of Norvasc

While this medication error affecting a 71-year-old patient didn't make many news headlines, it did become the subject of a 2016 Journal of Community Hospital Internal Medicine Perspectives article. An outpatient pharmacy accidentally dispensed the antipsychotic thiothixene (Navane) instead of the prescribed anti-hypertensive medication amlodipine (Norvasc). The patient took the wrong medication for three months, leading to physical and psychological harm. "Despite the many opportunities for intervention, multiple healthcare providers overlooked her symptoms," the authors noted.

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