Enhancing Quality and Safety: Medication Safety

Enhancing Quality and Safety: Medication Safety

Medication errors have significantly affected patient safety, as some have led to mortality or disability. Despite significant improvements by our health system to mitigate these errors, medication safety is still a concern due to various causes. The Food and Drug Administration (FDA) defines a medication error as an event capable of causing inappropriate medication use or patient harm in the hand of the prescriber, administering clinician, patient, or consumer of the medication (Center for Drug Evaluation & Research, 2019).

In the FDA’s definition, medication errors are preventable. The purpose of this paper is to describe a situation where a medication error occurred, explain the specific risks for the patient, and describe the best nursing coordination strategies to improve patient safety.

Patient Scenario

Charlie is a 22-year-old white male who had an emergency appendectomy following acute appendicitis. His pain persisted even on day four after the resumption of oral intake, and his surgeon prescribed oral morphine medication 10 mg start dose that evening. RN, the oncoming nurse that evening, administered 10 milliliters of morphine solution for injection infusion because the patient had been on other intravenous infusions in the postoperative period. The formulation given contained a 10mg/ml solution. Three hours about half an hour minutes after the administration of this solution, Charlie started vomiting the milk he had taken that evening and appeared to be in respiratory distress. Therefore, RN called Charlie’s surgeon to review him.

Factors Leading to Patient-Safety Risk

Various patient safety risks could have led to this patient’s risk for medication errors. These errors relate to healthcare professional practice, products, procedures, and systems. These errors can be traced back to product labeling, packaging, prescription, administration, and monitoring. These patient-safety risks related to medication administration include but are not limited to inadequate or unclear instructions, illegible writing, lack of medication reconciliation, improper administration documentation (Rosenthal & Burchum, 2020), inappropriate drug selection during administration, and failure to continue or discontinue medications. More than one risk can contribute to a single occurrence of medication error due to medication administration.

A qualitative study by Schroers et al. (2020) classified these patient safety risk factors in medication administration into personal factors and contextual factors. Personal factors include fatigue and complacency, while contextual factors include interruptions (Rosenthal & Burchum, 2020), night shift duty, unavailability of administration guidelines (Wondmieneh et al., 2020), and heavy nurse workloads. According to Rosenthal & Burchum (2020), about 60% of these medication errors occur during the care transition. Personal and contextual factors come into play at this time.

Improving Patient Safety Focusing on Medication Administration and Reducing Costs

Every healthcare organization continually works on various measures that they can use to prevent medication errors. Some of the evidence-based strategies to reduce medication errors, especially relating to medication administration, include but are not limited to the adoption of technology, bedside shift reporting, patient education, improving documentation in writing, and medication reconciliation. Adverse events from medication errors are too costly to the healthcare system and the patient. Treating adverse events due to medication increases the medical costs due to unintended patient harm and can cost the patient their lives.

The adoption of technology improves medication prescription and decision-making. According to Rosenthal & Burchum (2020), using technology reduces medication errors by 50%. The use of technology systems such as computerized physician order entry and computerized clinical decision support systems ensures that reduces errors of reception while the use of barcoded technology that identifies the drugs’ barcodes and against the patient information reduces errors of administration by up to 85% in some institutions (Rosenthal & Burchum, 2020). Therefore, technology can play a crucial role in the prevention of medication errors in the whole continuum of patient treatment.

Medication reconciliation is the process of comparing and updating the patient’s old and new medication lists. Medication reconciliation can be carried out at all care transitions, including inter-institutional transfer, admission, and discharge during shift reporting. About 60% of errors are reduced when medication reconciliation at all points of care transition. Bedside shift reporting offers an excellent opportunity for medication reconciliation during care transitions.

The Institute for Safe Medical Practices (ISMP) recommends using brand and generic names of medication during a prescription to ensure that during administration, the nurse is sure and less likely to make medication errors. The joint commission (TJC) banned the use of some abbreviations in prescriptions to reduce the chances of confusion during medication administration.

Improving documentation includes reserving verbal prescriptions for emergencies only. Documentation using electronic means ensures good communication between nurses, dispenses of medication, and prescribers of the medications. On the other hand, patient medication requires developing strong collaborative relationships that improve compliance with prescriptions to reduce the chances of medication errors (MacDowell et al., 2021). Education improves their understanding of the need for compliance and the potential side effects of overdose and toxicity.

Nursing Care Coordination to Increase Patient Safety

Nursing care is the center for care coordination in any healthcare institution. During care coordination, nurses organize patient care activities and share pertinent information with care stakeholders to ensure care effectiveness, safety, and quality (Agency for Healthcare Research and Quality, 2018). Care coordination aims at meeting patient care needs thus, the nurse needs to identify all patient needs and ensure they are met by the care providers. Some of the care coordination strategies that the nurse would employ include interprofessional collaboration and medication management. For example, during interprofessional collaboration, the nurse can help with care transition, assess patient needs, and share all relevant information.

The shared relevant information would be used to develop patient medication lists with a low risk of drug interaction and adverse events such as allergies. During care coordination, the nurse should also conduct medication reconciliation at every point of change in patient care providers. These two strategies would increase patient safety relating to medication administration.

Stakeholders During Care Coordination

The nursing care coordination must account for all relevant stakeholders of patient care. These stakeholders can be patient-specific and may not apply to all patient cases. Some of the key stakeholders that the nurse has to coordinate with include but are not limited to patient physicians, informaticists, pharmacists, patient caregivers, and the patient themselves. This coordination requires constant, timely communication and collaboration (Agency for Healthcare Research and Quality, 2018).

Collaboration with the patient or their caregivers would be important in safety monitoring and improving compliance with the prescription. Whenever in doubt, the nurse must coordinate with the prescribers of the patient medication lists to ensure that the correct drug and dosage are given to the patient, thereby lowering safety risks, especially due to administration. The nurse must coordinate with the pharmacists to ensure that the correct medication is dispensed. Their collaboration will also ensure that the risk of drug-drug interactions is lowered through medication reconciliation.

Another critical coordination is with fellow nurses. Collaboration with other nurses is essential in various ways. Firstly, it improves job satisfaction, thus lowering the chances of medication and medical errors. This interprofessional coordination and collaboration also enhance fast and smooth medication reconciliation (Tariq et al., 2022). This usually happens during shift handover. The exchange of other essential patient information at this time is also made easy through mutual information sharing and setting new care plans and care goals.


The medication error in this paper involved an overdose that could be due to a myriad of factors ranging from prescription to administration. Documented literature evidence has reported that medication errors due to medication administration arise from personal and contextual factors. Contextual factors are systemic and relate to the circumstances of the error occurrence. Personal factors related to complacency and fatigue from nurses. To improve patient safety by preventing medication errors, the nurse should adopt strategies such as medication reconciliation, the use of technology, improving documentation, and patient education. Nursing care coordination strategies such as identifying patient needs and sharing information should involve all pertinent patient care stakeholders. The patient caregivers, doctors, pharmacists, informaticists, the patient themselves, and other nurses and key stakeholders that the nurse will require to communicate and collaborate with to improve patient safety. Medication reconciliation at every point of care transition will be important during the coordination process.


Agency for Healthcare Research and Quality. (2018, August). Care Coordination. Ahrq.gov. Retrieved from https://www.ahrq.gov/ncepcr/care/coordination.html

Center for Drug Evaluation & Research. (2019, August 23). Working to Reduce Medication Errors. U.S. Food and Drug Administration. Retrieved from https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors

MacDowell, P., Cabri, A., & Davis, M. (2021). Medication Administration Errors. Intensive Care Medicine. https://psnet.ahrq.gov/primer/medication-administration-errors

Rosenthal, L., & Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. Joint Commission Journal on Quality and Patient Safety47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication dispensing errors and prevention. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(1), 4. https://doi.org/10.1186/s12912-020-0397-0