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.

Medication Safety Officer

Tremendous improvements in medication safety have been made in the past two decades however, new therapeutics, emerging technologies, complex drug management systems, changes in staffing patterns and workflows continue to pose significant challenges. In addition, external factors such as drug shortages as well as competing demands from regulatory agencies, accrediting bodies, third-party payors, and patients substantially impact error prevention measures. While reducing medication errors remains a top priority for most health care executives, they often do not have adequate time to devote to this issue. To alleviate this hurdle, many hospitals have created a Medication Safety Officer (MSO) position.
An MSO is a dedicated clinical advocate with specific education, authority, and leadership skills to serve as the organization’s expert in safe medication practices. Qualified pharmacists, nurses, physicians and physician assistants may fill this role with titles such as medication safety leader, medication safety manager, medication safety coordinator, medication safety clinical specialist, or director of medication safety. This responsibility does not fall solely on the shoulders of the MSO but is shared among all health care practitioners who procure, prescribe, prepare, dispense, administer, and monitor medications. However, the MSO has the ability to affect change from the top, to ensure the organization learns from medication risks and errors, and to implement high-level strategies. An MSO can interact with frontline clinicians to champion past safety achievements, making them more widespread and sustainable.
An effective MSO possesses detailed knowledge of the science of patient safety and reliability, quality improvement principles, human factors, Just Culture, event investigation, system design, medication-related technologies, error-reduction strategies, change management, and medication safety measurements. They should also have an in-depth understanding of the entire medication use process and the ethics of transparency and disclosure. The position of the MSO requires strong communication, interpersonal, and leadership skills. They should be innovative and visionary, and they must have the ability to influence the behavior of others.
There are nine essential MSO roles that are critical to success:
  1. Champion and Diplomat – the MSO should be visible and present on clinical units to listen to staff regarding current practices.
  2. Information Steward and Communicator – as an expert on safe medication practices, the MSO may conduct literature searches on best practices, participate in safety research projects, disseminate new information to staff, write a medication safety-related newsletter or organize educational programs.
  3. Strategist and Influencer – the MSO prioritizes medication safety as a core value for individual clinicians and the organization. The MSO may present evidence for specific strategies to executive leaders, board members, and medical staff.
  4. Ethical Negotiator – as a leader, the MSO must maintain ethics, transparency, and disclosure in order to foster trust and to promote error reporting.
  5. Cross-discipline Team Leader – the MSO must have the ability to work along the chain of command and across various clinical departments.
  6. Data Optimizer – the MSO must investigate medication error-reporting data and assess whether strategies are having a positive impact. The MSO may participate in root cause analysis (RCA), analyze medication-related technology data (i.e. from infusion pumps, bar-coding technology, automated dispensing cabinets) in order to develop and implement effective action plans.
  7. Proactive Facilitator – the MSO should proactively identify medication risks that can lead to patient harm, investigate the causes, and implement risk-reduction plans.
  8. Compassionate Just Culture Mentor – the MSO must develop trust in order to advise others to make behavioral choices that are consistent with the organization’s culture and values. The MSO should encourage the reporting of medication errors, console staff who make medication errors, and help redesign medication use systems to reduce or eliminate errors. The MSO may help develop, conduct, or report the results of an organization-wide culture survey. The MSO may also assist in determining if a mistake is due to human error, at-risk behavior, or reckless behavior and advise the manager on how to respond.
  9. Agent of Change – the MSO works to identify and understand challenges to medication safety, creatively problem-solve, and drive solutions into practice.
The MSO should be a member of the leadership team with full authority to act and remove barriers to change. The MSO position should also have complete support of the executive team.

Safety Issues

Shoulder Injury Related to Vaccine Administration
There have been many reports of shoulder injury related to vaccine administration (SIRVA). These injuries include pain at the injection site, pain in the shoulder and shoulder joint, or inability to move or raise the arm. Symptoms may persist for weeks. Patients indicated that the clinician administered the COVID-19 vaccine high on the upper arm. There are many clinicians who do not normally administer vaccine but are volunteering in the national COVID-19 vaccination effort. It is essential that these health care workers review and fully understand proper intramuscular (IM) administration technique to avoid SIRVA and other complications.
Vaccine Card for Single-Dose COVID-19 Vaccine
The vaccine record cards that are currently given following COVID-19 vaccination reference two-dose vaccines only. These cards accompany the Moderna and Pfizer-BioNTech vaccines and include space to document the product name, manufacturer, lot number and first and second vaccine doses. The back of the card includes a reminder to return for a second dose. Since the Johnson & Johnson (J&J) Janssen COVID-19 vaccine requires only a single-dose, this may confuse some patients. At this time, the Centers for Disease Control and Prevention (CDC) is not planning to update the vaccine cards for the Janssen single dose. For now, hospitals and clinics are advised to apply a label on the card to note that a second dose is not required for the Janssen vaccine. A label can also be applied on the back to cover the statement about returning for a second dose. Clinicians should reinforce that a second dose is not needed for the J&J Janssen vaccine.

  1. Institute for Safe Medication Practices. (2021). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices:

Previous issues


March 2021: Just Culture  
February 2021: COVID Vaccine Errors  
January 2021: Shoulder Injuries from IM Injections  



December 2020: Standardizing Drug Infusions December 2019: Confusing Naming Methodologies
November 2020: IV Infusions November 2019: Speaking Up
October 2020: Heparin October 2019: Literature Review of Independent Double Checks
September 2020: Avoid Blame September 2019: Safe Injection Practices
August 2020: NRFit August 2019: Methotrexate Mistakes
July 2020: Education July 2019: Reducing Risks in Medication Administration
June 2020: COVID Related Med Errors June 2019: Independent Double Checks
May 2020: Leadership During COVID-19 May 2019: Newborn Patient Mixups
April 2020: Infusion Pumps Outside COVID-19 Patient Rooms April 2019: Hefty Subcutaneous Doses
March 2020: COVID-19 March 2019: Epidural Antibiotic Mix Up
February 2020: Oxytocin Errors February 2019: Criminal Indictment
January 2020: Reporting Errors to ISMP 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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