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.

Drug Errors Related to COVID-19

Several medication administration issues have arisen during the coronavirus pandemic. The following drug errors and concerns have been reported.

Remdesivir has been used to treat COVID-19 patients through the U.S. Food and Drug Administration (FDA) emergency use authorization (EUA) program. An initial loading dose of 200 mg is typically administered followed by 100 mg doses. The drug is available in two dosage forms: lyophilized powder for injection and a solution for injection. The label for the lyophilized powder lists the total drug amount as 100 mg per vial. The injectable solution label lists the per mL strength (5 mg/mL) with the total volume below (Contents: 21.2 mL). Yet another label for injectable solution lists the total dose per total volume first (100 mg/20 mL) with the per mL amount (5 mg/mL) below it. Two factors have resulted in mistakes:
  1. Confusion with the labeling of the injectable solution vial, which does not include the total dose (100 mg) contained in the vial.
  2. Confirmation bias – for example, a technician, having just prepared the loading dose of 200 mg, used two vials to prepare subsequent doses. The pharmacist did not catch the error as there were no barcodes available to scan the vials. The 200 mg doses were also erroneously labeled 100 mg doses.
To prevent these errors:
  • Add a printed barcode label to each remdesivir container to facilitate product and dose verification.
  • Placing an auxiliary label on remdesivir injectable solution vials to indicate the total amount of drug (100 mg) contained.
  • Provide prescribers, pharmacy staff, and nurses with fact sheets and/or pharmacy guides provided by the manufacturer.
Bypassing the Barcode Medication Administration (BCMA) System
The COVID-19 pandemic often required the reassignment of staff to different units. Some of these clinicians, such as operating room nurses, are not familiar with BCMA and would bypass the system to administer medications, resulting in errors. Redeployed nurses require orientation to the newly assigned unit including the patient population, technologies, processes and medications.

Telehealth Issue
Many clinics are providing telehealth visits for patients who can’t be seen in person during the pandemic. One issue that has arisen is the inability to obtain an accurate weight, resulting in wrong doses of weight-based drugs. One example involved a cancer patient who had not been seen for months and lost a significant amount of weight. Her chemotherapy plan used her previous weight from four months prior. The nurse double-checked the order and noticed the patient’s body surface area (BSA) had decreased 7% compared to the BSA on her chemotherapy treatment plan. The order was changed however it resulted in a two-hour delay. The institution is changing the electronic health record to require an updated weight before prescribing, dispensing, and/or administering weight-based medications. Clinicians should also ask the patient about recent weight loss or gain during telehealth visits.

Automated Dispensing Cabinet (ADC)
Medication errors can occur when clinicians enter only a few letters in an ADC drug name search. One patient received a dose of verapamil instead of versed when a nurse used the override feature on the ADC and selected the wrong drug. She also did not use the bedside barcode scanning system since the medication was a verbal order and had not been entered into the electronic health record. The institution is assessing its verbal order practices and plans to phase out their use except in emergencies. They are also auditing the ADC override practices and plan to restrict their use. One recommendation to help reduce these errors is to increase the number of letters needed (minimum of five) when searching for drugs in the ADC.

Missed Doses
There have been several reports of missed doses of albuterol inhalers due to communication issues between nurses and respiratory therapists. Missed drug doses have also occurred due to the need to consolidate medication administration times in order to limit the frequency that nurses enter patients’ rooms.

New Formulation for Nymalize

Nymalize (nimodipine) is used to decrease the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage (SAH) and is only administered orally. It may be used off-label in pediatric patients to prevent cerebral vasospasm after intracranial aneurysm rupture or following cerebral trauma. Mistakes have occurred when the drug was withdrawn from liquid-filled gel capsules with a syringe and needle to administer through a feeding tube. This practice has resulted in the drug being erroneously administered intravenously (IV) which can cause significant hypotension and potential death.
The following changes were made to Nymalize packaging and concentration:
  • The concentration was increased from 3 mg per mL to 6 mg per mL to reduce the volume per dose.
  • The drug was packaged in prefilled oral syringes of 30 mg per 5 mL or 60 mg per 10 mL.
  • The product will no longer be marketed in 10 mL or 20 mL unit dose cups or as a 473 mL (pint) bottle.
  • Issues with new packaging:
    • Not all feeding tubes will accommodate an oral syringe.
    • Nymalize oral syringes will need to be repackaged to be compatible with ENFit tubing as legacy feeding tubes, adapters and administration sets will be phased out over the next year.
    • Pediatric patients require a weight-based dose (1 mg/kg every 4 hours). For many children, only a portion of a 30 mg or 60 mg oral syringe will be needed. To prevent potential dosing errors, the syringes should not be stored in ADCs and doses should not be prepared on nursing units. Pediatric-specific doses should be prepared in the pharmacy from new oral syringes.

Methadone Overdose

To reduce errors with methadone prescribing and potential overdosing:
  • Order entry systems should be designed to automatically select the most appropriate concentration of the product based on the patient’s dose. For example, if the dose is 10 mgs or less, the system should default to a 1 mg/mL oral solution. Conversely, if the dose is greater than 10 mg, the system should default to a 10 mg/mL concentration.
  • Pharmacy-prepared oral syringes in patient-specific doses should be dispensed for inpatients since nurses typically equate one syringe with one dose. This also decreases waste and potential drug diversion. When possible, one package should equal one dose.
  • If medications must be prepared in the pharmacy in batches, instead of the exact dose needed for each patient as prescribed, the barcode on the batched product should be the only available barcode for nurses to scan at the bedside. The barcode system would then alert the nurse if the patient’s dose is different from the amount in the batched container. The system would also advise the nurse to administer a partial dose.

Safety Issues

Pill Crusher Syringe
The PillCrusher is an enteral syringe that can crush and dissolve tablets and then administer the drug directly to the patient. The syringe can also be used for enteral irrigation. There are problems with the use of the PillCrusher:
  • The devices are not ENFit compatible.
  • They should not be used on tablets that are not designed to be crushed such as long-acting or enteric coated pills as these can damage the syringe and cause plastic to shed off.
  • Pharmacists can help nurses by crushing tablets while in the unit dose package or by supplying liquid doses in place of tablets.
  • Disperse tablets in water without crushing and draw into an oral/enteral syringe.
  • Choose a different type of pill crusher and transfer the tablet to a cup or ENFit oral syringe to dilute and then administer.

Phasing Out Legacy Feeding Tubes

Manufacturers will begin phasing out legacy feeding tubes on July 1, 2020. There will also be an industry-wide discontinuation of transition adapters as these will not be needed moving forward. ENFit feeding systems will be the standard as this product decreases the risk of misconnections with vascular lines or other tubing connections (i.e. irrigation lines, neuraxial access lines). Organizations should be in the process of converting to the ENFit systems and should communicate this change to the entire community including purchasers, clinical personnel (pharmacists, nurses, interventional radiologists, and physicians who insert gastrointestinal tubes).

Instanyl (Fentanyl) Nasal Spray

Instanyl is a brand of fentanyl nasal spray available in Europe to treat breakthrough pain in cancer patients. A young German man accidentally took two sprays of his partner’s fentanyl nasal spray confusing it with a nasal decongestant spray. He experienced respiratory depression, loss of consciousness and ultimately did not survive. While the spray is supplied in childproof packaging, mistakes can still happen if the bottle is not returned to the storage case. Lazanda, a similar product available in the U.S., is supplied in a child-resistant glass bottle and is only available through a restricted program called the Transmucosal Immediate Release Fentanyl (TIRF) Risk Evaluation and Mitigation Strategy (REMS), designed to minimize risks of misuse, abuse, addiction, overdose, and serious complications. Pharmacists, distributors and prescribers are required to enroll in this program. Prescribers should educate patients about the risks, potential mix-ups with other nasal sprays, how to properly store the drug and dispose of excess medication. They should also emphasize the adverse effects of fentanyl spray if used by others. One specific recommendation, not included in the product label for Lazanda, is the need to prescribe and dispense naloxone for patients taking opioids at home.

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

Previous issues



May 2020: Leadership During COVID-19 December 2019: Confusing Naming Methodologies
April 2020: Infusion Pumps Outside COVID-19 Patient Rooms November 2019: Speaking Up
March 2020: COVID-19 October 2019: Literature Review of Independent Double Checks
February 2020: Oxytocin Errors September 2019: Safe Injection Practices
January 2020: Reporting Errors to ISMP 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

More Nursing News Headlines (Pharmacy)...

Powered by