Medication Errors

Medication safety is a top priority for nurses and avoiding medication errors is critical. Find out what medication errors have recently been reported to the Institute for Safe Medication Practices (ISMP) and learn recommendations for best practices to help avoid these errors.


Verbal Order Errors Continue

Verbal orders, while highly discouraged in most health care settings, are still used widely today. Verbal orders may be necessary in certain situations such as emergencies and during sterile procedures. However, verbal orders are often misunderstood, misheard, or transcribed incorrectly and therefore highly prone to error. Add various accents, dialects and pronunciations by the prescribers as well as sound-alike drug names and dosing numbers, background noise and distractions and you have a recipe for confusion and mistakes.
Verbal orders are typically received via telephone, face-to-face, or by voicemail. The Joint Commission (TJC) includes a requirement under the Provision of Care, Treatment, and Services (PC 02.01.03, EP 20) for the receiver of a verbal order to record it and read (not repeat) it back to the prescriber. Unfortunately, this best practice occurs less than half of the time for some practitioners to almost never for others. Errors associated with verbal orders includes:
  • Transcription errors
  • Misheard sound-alike drug names
  • Prescriber confusion
  • Misheard dose
  • Misunderstood dose
  • Misheard frequency
  • Route confusion
The following recommendations may reduce errors associated with verbal orders:

Prescribers and Receivers of Verbal Orders
  • Prohibit verbal orders for chemotherapy, except to hold or discontinue.
  • Limit verbal orders to true emergencies or in situations which the prescribers is physically unable to electronically send, write or fax orders such as working in a sterile field.
  • Limit verbal orders to formulary drugs which will prevent unfamiliar drugs from being misheard.
  • Define the process including limitations on verbal orders, elements of a complete verbal order, requirements for communication of verbal orders, direct transcription into the medical record and the readback process for verification.
  • Clarify all communications: avoid drug name abbreviations and error-prone dose, route or frequency abbreviations. Spell out drug names and individual dose, not a total daily dose, and pronounce each digit of a number separately.
  • Wait until the receiver of the order is in front of a computer with the patient’s record pulled up to directly enter the order.
  • Identify patient using the full name and birth date, and confirm allergies with the order receiver.
  • Speak clearly and ask the receiver to read back the order as transcribed in the patient’s medical record.
  • Provide the indication for the medication to help prevent confusion with sound-alike medications.
  • Provide complete orders including the unit of measure for each dose and frequency of administration.
  • Avoid voicemail orders in the inpatient setting; in the outpatient setting, repeat orders on voicemail a second time.
  • Provide weight-based doses, including mg per kg dosage, with the patient-specific dose for all weight-based neonatal and pediatric orders.
  • Request patient verification by asking the recipient to read back the patient’s name and birth date on the screen or order form.
  • Verify the order by reading it back to the prescriber. This is the most important strategy to reduce errors with verbal orders.
  • Immediately transcribe verbal orders directly into the medical record.
  • Make sure the verbal order makes sense and is related to the patient’s condition. Record the medication’s indication, per the prescriber, directly on the order or with the order.
  • Discourage verbal orders by not accepting them if the prescriber is present and able to document the order.
  • Do not accept verbal orders from a “middle-man” such as office staff who is not the original prescriber.
  • Do not accept verbal orders for chemotherapy.
  • Do not accept abbreviations, instead transcribe and read back the meaning of the abbreviation instead of the abbreviation itself.

Common Drug Name Stem “-mab”

Drugs with a suffix “-mab” belong to the family of monoclonal antibodies (mAb), which bind to specific targets within the body and treat autoimmune diseases, various types of cancer, and hypercholesterolemia to name a few. The prefix helps differentiate each monoclonal antibody. The substem A indicates the target of the antibody such as tumor “-t(u)-”, bone “-s(o)-“, and immunomodulating “-l(i)-“. The substem B is found immediately before the suffix and identifies the source of the antibody, such as “-zu-“ for humanized, “-o-“ for mouse, “-u-“ for fully human, and “-xi-“ for chimeric which is part-mouse, part-human. Since non-human antibodies are considered foreign by the body’s immune system, patients may develop an allergic reaction or decreased response over time. Some monoclonal antibodies require pre-treatment with acetaminophen, an antihistamine, and/or a steroid to mitigate infusion-related reactions. Signs of an infusion reaction include fever, nausea, vomiting, diarrhea, skin rashes and changes in heart rate and blood pressure. The reaction may occur within 30 minutes to 2 hours after starting the infusion. If your patient is prescribed a drug with the suffix -mab, be sure to monitor for any infusion reactions and consider pre-medication prior to administration.

Safety Issues

Errors with “Meds to Beds” Prescription Bags at Bedside
“Meds to Beds” programs bring prescription medications to the patient’s bedside before the patient is discharged from the hospital. The service may include patient medication education and follow-up by a pharmacist after discharge. These services, which are provided by the hospital ambulatory care pharmacy or by external community pharmacies, may lead to increased medication compliance and reduced patient readmissions. To prevent errors or confusion between discharge drugs and in-hospital drugs, the medications should not be dropped off or left unsecured at the patient’s bedside. The hospital should have a protocol in place to secure these medications until discharge, after a pharmacist has reviewed them with the patient, and what to do if the patient is not in the room at the time of delivery. An additional label should be applied to the bag containing the medications to remind the patient that the drug(s) is not to be used in the hospital.
VinCRIStine Extravasation
New recommendations suggest that VinCRIStine should be diluted in a minibag instead of administering the drug via a syringe. This reduces the risk of extravasation as well as potential mix-up with intrathecal medications, which could be fatal. The Johns Hopkins Hospital reviewed 1,300 cases of VinCRIStine minibag infusions, in which no cases of extravasation occurred. This practice is supported by The Joint Commission, the World Health Organization, the Oncology Nursing Society and the National Comprehensive Cancer Network.
Oral Chloral Hydrate Use in Pediatric Sedation
The Institute for Safe Medication Practices conducted a survey of over 400 pharmacists, nurses and physicians on the use of chloral hydrate for pediatric procedural sedation in 2016. The commercial product was discontinued in 2012 and approximately 60% of respondents reported no longer using chloral hydrate. However, almost 30% reported continued use of the drug for pediatric sedation in both inpatient and outpatient settings where the drug is compounded by the hospital pharmacy, a compounding pharmacy or ambulatory pharmacy. Reasons for continued use include: past experience with positive outcomes, efficacy, low cost, inadequate alternatives, as safe as other alternatives, lack of availability of anesthesia professionals, and fewer sedation failures than alternatives. The most common adverse events reported include: patient’s refusal of the medication or vomiting; sedation failures leading to inability to complete procedures; and prolonged sedation. Other adverse events reported were airway obstruction, respiratory depression, hypercapnia, respiratory arrest, excessive sleepiness, post-discharge sedation, hypotension, and cardiopulmonary arrest. While the majority of respondents do not think chloral hydrate should be used in pediatric sedation procedures, almost 20% still believe it is indicated for procedures such as radiology imaging, neuroimaging, and electrocardiology/echocardiology procedures; pulmonary function tests; emergency department procedures such as suturing; special hearing tests; and dental procedures conducted in the hospital.

  1. Institute for Safe Medication Practices. (2017). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

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