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.

Errors Happen in Clinical Education

Students in every health care discipline, including medicine, nursing and pharmacy, are required to complete mandatory hours in direct patient care in a variety of clinical settings. These rotations ensure that each student gains valuable real-world, hands-on experience that helps them attain the skills required to confidently and competently care for patients. Guided by instructors and preceptors, students perform a multitude of tasks while learning effective patient management. However, even under the watchful eye of their mentors, students are subject to similar errors that occur with veteran clinicians.
Student errors commonly reported include:
  • Confusing medications due to look-alike labels and packaging.
  • Mental mistakes due to distraction.
  • Duplicated and/or omitted care when students are assigned to the same patient as hospital staff.
  • Medications given twice or not given at all due to miscommunication.
    • Most common high-alert medications involved with student errors are insulin, opioids, and anticoagulants.
Earlier this year, the Canadian Institute for Medication Safe Practices analyzed its database of student-associated medication errors. The analysis revealed several strategies to improve training and reduce potential adverse events.
  • Encourage students to recognize, resolve, and report medication errors.
  • When pairing a student with a preceptor, ensure the workload is appropriate to allow adequate time for mentoring and training.
    • Avoid pairing the preceptor with multiple students.
    • Avoid precepting students in multiple locations.
    • Ensure the preceptor does not have additional clinical responsibilities.
  • Provide adequate training to students and review hospital policies and procedures before they perform new tasks and skills.
  • Avoid error-prone processes and short-cuts.
    • Teach students to avoid concurrent preparation of medications for several patients.
    • Instruct students to label all medications in syringes.
Often, inexperience is associated with higher rates of error however, students may provide fresh perspectives and their inquisitive nature can help foster a culture of safety in any health care environment. Healthcare leaders and organizations must do their part to provide training settings that promote safe medication practices that allow clinicians to use their knowledge to decrease potential errors.

Safe Intravenous Practice Reminder

It is important to remind your clinical staff to properly flush intravenous (IV) tubing after administering all IV push medications. IV tubing along with needleless ports and stop-cocks could contain 10 mL or more of uninfused medication. Residual drug in IV tubing can have serious adverse effects. Of particular concern are anesthetic drugs and neuromuscular blocking agents that are used in operating rooms (OR) which may remain in IV tubing upon transfer to the post-anesthesia care unit (PACU). An overdose of these drugs may cause paralysis, respiratory depression, apnea, and possibly death.
To prevent infusion of residual medications in IV tubing such as neuromuscular blocking agents following surgical procedures:
  • Flush IV tubing adequately and per hospital policy.
  • Change IV line before patient is extubated following surgery per hospital policy.
  • Remove the source container.
  • Verify these steps have been taken when patient is transferred (i.e. from operating room to post-anesthesia care unit) and communicate all medications that were administered via IV lines.

High Alert Medication Update

The following updates have been made to the list of high alert medications:
  • Antithrombotic agents were expanded to include direct oral anticoagulants.
  • Minimal sedation agents were added to the category of oral moderate sedation agents for children.
  • Oral hypoglycemic category was changed to oral sulfonylurea hypoglycemics
  • IV radiocontrast media was removed from the list
  • IV promethazine was changed to promethazine injection to include administration by any parenteral route

Safety Issue

Sertraline Oral Concentrate Must Be Diluted
Sertraline, a selective serotonin reuptake inhibitor antidepressant, comes in an oral liquid concentrate (20 mg/mL) that must be diluted before administration to make it more pleasant and tolerable for the patient to drink. If given undiluted, the solution may cause numbing of the tongue and mouth for an extended period of time. Sertraline product labels include a warning to dilute before administration as well as mixing instructions on the manufacturer’s carton labels. However, these labels warnings may be missed by clinicians.
To safely administer sertraline oral concentrate:
  • Use the manufacturer-provided dropper to measure the dose of solution.
  • Mix the measured dose with 4 ounces (1/2 cup or 120 mL) of water, ginger ale, lemon/lime soda, lemonade or orange juice only – do not use other liquids. A slight haze is normal.
  • Include directions for dilution on the electronic medication administration record (MAR).
  • Require pharmacy to place an auxiliary label on unit doses dispensed in oral syringes, instructing nurses to dilute the solution immediately prior to administration.
  • Provide instructions to patients and caregivers on the proper method to dilute the oral solution as well as the appropriate diluents to use.

Influenza Vaccine for Healthcare Providers
All healthcare providers should make it a habit to get the influenza (flu) vaccine each year which protects your family, your patients, and your colleagues from getting sick. Influenza epidemics in hospitals and long-term care facilities are often caused by staff who fail to get vaccinated for the flu. If your place of work does not offer the vaccine, contact your personal healthcare provider or local pharmacy.


  1. Institute for Safe Medication Practices. (2018). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

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