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.

How Leaders Can Support Staff During the Pandemic

During this unprecedented time, healthcare providers are putting aside their own safety and working under extremely stressful conditions to combat COVID-19. This can have an immense impact on clinicians’ mental and physical wellbeing. They experience both tremendous grief for their patients as well as fear of spreading the virus to their loved ones, forcing many to self-isolate from their families. This concern is compounded by the shortage of personal protective equipment (PPE) in many hospitals. About 10% of healthcare workers have been hospitalized and 27 individuals have lost their lives to the virus. In addition, wearing PPE for a full shift can cause dehydration, backaches, headaches, and skin injuries.

Leaders play an important role in supporting their staff, particularly now. However, a recent survey found only half of respondent felt their employer communicated a clear plan for COVID-19 and one in five feel their employer did not communicate enough about COVID-19. Two out of three were not confident about their safety at work based on their organization’s policies. Leaders need to be strong communicators and listeners, prioritize their staff’s safety and show appreciation for their employees. Several strategies that leaders can employ include:
  • Create a safe space
    • Designate an area where staff can step away from the bedside to relax, reflect and unwind.
    • Provide psychological counselors for both private and group sessions.
    • Encourage employees to use social media to connect with family and friends.
  • Promote trust and compassion - Staff may suffer from burnout and feel guilty about poor patient outcomes, second guessing their clinical knowledge.
    • Encourage staff to feel compassion for themselves and others by strengthening trust and fairness in the workplace.
    • Train peer supporters to console staff who are feeling burnout or guilt.
    • Assist workers in dealing with their reactions to the pandemic chaos.
  • Endorse a positive mindset to promote wellbeing
    • Positive thoughts and emotions improve physical health, protect against depression, reduces stress, and boosts resilience.
    • Remind staff that their work is meaningful.
    • Celebrate patient recoveries and discharges and other victories in the workplace.
  • Communicate with transparency
    • Creates trust and loyalty, facilitates feedback of concerns and ensures everyone is on the same page.
    • Listen to staff, avoid making assumptions and do not try to solve issues too quickly.
    • Encourage staff to express their worries, offer ideas, and collaborate on solutions.
    • Acknowledge challenges, frustrations, and feelings of isolation and loneliness.
  • Be Present
    • Be visible to staff at the bedside.
    • Be open to questions and concerns.
    • Show gratitude and recognize the work of your employees.
  • Build Community
    • Support opportunities for staff to develop meaningful connections.
    • Encourage social interactions among co-workers who may be separated from their families.
  • Promote Self-Care
    • Recommend habits that foster physical and psychological wellness such as adequate sleep, exercise, music, meditation, and diet.
    • Support feelings of gratitude, kindness and forgiveness.
The COVID-19 pandemic will undoubtedly have a profound impact on healthcare providers and may cause or exacerbate depression and anxiety, exhaustion and isolation as well as post-traumatic stress disorder and suicide. Leaders should be acutely aware of these potential negative effects and strive to establish a positive and supportive work environment.

COVID-19-Related Medication Errors

Hospitals should develop a system for reporting errors that may be related to COVID-19. This would allow for swift risk assessment on emerging issues. Some issues that have been uncovered include:
  • Nurses redeployed to other areas of the hospital require orientation to the patient population, technologies, processes and medications.
    • Operating room nurses may not be familiar with the use of barcode medication administration at the bedside and errors have occurred due to missed barcode scanning.
    • Incorrect inhalers have been administered due to a lack of knowledge or experience with these drugs.
  • Miscommunication between nursing and respiratory therapy caused missed doses of albuterol treatments.
  • Inappropriate return of COVID-19 patient medications to the pharmacy.
  • Inadequate flushing of extension tubing when intravenous (IV) pumps were placed outside of patients’ rooms.

Change in ADC Protocols

COVID-19 has necessitated a change in protocols related to automated dispensing cabinets (ADCs) in order to prevent cross-contamination, secure storage, return medications to the pharmacy, and maintain safe practices.
  • Accessing the ADC
    • Perform hand hygiene before and after accessing the ADC.
    • If wearing gloves, be sure they are clean and uncontaminated before accessing the ADC, then discard immediately after access followed by hand hygiene. Gloves may interfere with fingerprint scanning. If permissible, disable the fingerprint function and use retinal scanning or username and password.
    • Disinfect common touch points on the ADC after use.
  • Reduce traffic and inhibit cross-contamination
    • Temporarily increase drug par levels (stock per day) to reduce restocking and thus traffic to the ADC.
    • Stock medications in multiple ADC bins with few doses per bin to minimize contamination.
    • Store as many drugs as possible in locked-lidded bins to decrease risk of cross-contamination.
  • Store critical supplies under lock and key
    • Keep PPE locked in ADCs or other containers to limit access and track inventory.
    • Place high-demand medications or those in low supply or requiring tighter control in locked-lidded bins and conduct periodic counts of those medications.
  • Avoid returning medications
    • To limit errors and cross-contamination, do not return medications that are removed from the ADC.
    • Utilize a common, secure, one-way return bin to send back unused medications to the pharmacy as long as they have not been placed in a patient’s room.
  • Sustain safety protocols
    • When removing high-alert medications from an ADC via override, ensure a documented independent double check is performed by another clinician.
    • Employ ADC dispensing alerts to give practitioners critical information about new or unfamiliar drugs to assist clinicians that may be working outside their normal practice area.
  • ADC Redeployment         
    • Follow guidelines when moving an ADC system.
    • Rename the redeployed ADC to match the new locations and stock it with carefully selected medications at storage levels appropriate for the new patient care area.

Ascorbic Acid Interferes with Glucometer Results

High dose ascorbic acid (Vitamin C) has been administered IV to COVID-19 patients to help fight infection. High-dose IV ascorbic acid may cause falsely elevated glucometer results which may in turn result in unnecessary insulin doses and subsequent hypoglycemia. To prevent this adverse event, require laboratory confirmation of glucometer results above 200 mg/dL for any patient receiving IV ascorbic acid.

Extension Tubing Hazard

When placing IV pumps outside of a patient’s room with long extension tubing, be sure to secure the tubing to the floor to prevent a tripping hazard. Tubing may become disconnected from the patient and the patient may not receive the correct amount of medication if any at all. If this practice is implemented in your institution, be sure the correct protocols are in place to prevent these hazards from occurring.

Institute for Safe Medication Practices. (2020). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:  

Previous issues



April 2020: Infusion Pumps Outside COVID-19 Patient Rooms December 2019: Confusing Naming Methodologies
March 2020: COVID-19 November 2019: Speaking Up
February 2020: Oxytocin Errors October 2019: Literature Review of Independent Double Checks
January 2020: Reporting Errors to ISMP September 2019: Safe Injection Practices
  August 2019: Methotrexate Mistakes
  July 2019: Reducing Risks in Medication Administration
  June 2019: Independent Double Checks
  May 2019: Newborn Patient Mixups
  April 2019: Hefty Subcutaneous Doses
  March 2019: Epidural Antibiotic Mix Up
  February 2019: Criminal Indictment
  January 2019: Confusing Glucometer Results



  December 2017: Ongoing Debate Texting Medical Orders
November: Dangerous IV Push Medication Practices November 2017: Dangerous Injection Practices
October 2018: Tracheostomy Balloon Port October 2017: Medication Safety Assessment
September 2018: Errors in Clinical Education September 2017: Heparin Induced Thrombocytopenia
August 2018: Smart Pump Low Concentration August 2017: Insulin Syringe Issues
July 2018: Ellipta July 2017: Texting and Patient Management
June 2018: Rituxan Subcutaneous vs IV June 2017: Verbal Order Errors
May 2018: Nebulized Medications May 2017: Unsafe Infusions & Injection Practices
April 2018: Surgical Fires April 2017: Generic Medication Names
March 2018: Treating Hyperkalemia With Insulin March 2017: Medication Errors at Home
February 2018: Barcode Errors February 2017: Errors in Irrigation
January 2018: Smartpump Miscommunication January 2017: Use Technology Wisely

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