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.

Independent Double Checks

Independent medication verifications have been known to prevent potential drug errors. Attitudes towards these independent double checks varies among practitioners – some rely heavily on them while others find them to be inconvenient for several reasons including:
  • Process can be time consuming
  • Perception they are impractical due to limited staffing and workflow interruptions
  • Diminished effectiveness due to inconsistent and variable use
  • Considered an inferior method to reduce drug errors
Regardless of these negative notions, studies have shown that independent double checks can help reduce 95% of errors. Effectiveness depends on multiple factors such as:
  • Independent check is performed by another qualified staff member
    • Reduces confirmation bias
  • Use of independent double check is reserved for a select subset of high-risk tasks, vulnerable patients, or high-alert medications
    • Processes and medications that are at highest risk for errors:
      • Intravenous (IV)/epidural opioids
      • IV insulin
      • IV heparin
      • IV chemotherapy
  • Accurate assessment of the need for independent double checks:
    • Why is an independent double check used and what needs to be verified?
    • Is an independent double check the most effective way to find or prevent errors?
      • In some cases, bedside barcode scanning or other processes may be more reliable.
    • How do independent double checks integrate with other risk-reduction strategies?
      • Some protocols integrate multiple checks throughout the procedure (i.e. various healthcare professionals calculate a chemotherapy dose at multiple points in the process – prescriber, pharmacist, nurse practitioner and clinical nurse).
  • Utilization of resources to pinpoint those processes and medications that are highest risk:
    • Failure mode and effects analysis (FMEA)
    • Hazard and event analysis
    • Review of literature
    • Risk and error reports
  • Avoid use of independent double checks to correct issues that require a system change; instead evaluate other strategies such as computer alerts with hard stops, standardization, and barcode scanning.
  • Do not rely on independent double checks alone.
    • External factors may play a role such as poorly designed drug packages and labels, complex administration processes or confusing information.
Independent double-checks may fail to detect and prevent an error for several reasons:
  • Habitual checks lead to auto-processing; clinicians may become careless and inattentive.
  • When initial information appears accurate, staff may not look for other areas of potential error.
  • Clinician is uncomfortable evaluating a peer’s work or uncomfortable asking questions.
  • Provider holds too much trust in the person whose work is being checked.
  • False sense of security, relying heavily on other staff to catch mistakes.
  • Distractions and interruptions prevent the independent check from being completed.
In addition to the “Five Rights” of medication administration (right patient, right drug, right dose, right route and right time), clinicians must remember to ask these questions:
  • Is the drug appropriate for the patient?
  • Does the drug’s indication match the patient’s diagnosis?
  • Is the dose correct for this patient?
Standardize the Process
  • Establish a standardized process to decrease variation and inconsistencies.
  • Ensure staff understand the goals of the independent double check and the steps to be followed.
  • Design the process so it is easy to follow and document; use checklists (electronic or paper) that include very specific instructions.
  • Are independent double checks being used properly?
  • What errors need to be uncovered?
  • Are independent double checks the best strategy to decrease medical errors?
  • Are there other high-alert medications or vulnerable steps in critical processes that need an independent double check?
  • Monitor staff compliance.
  • Assess how often checks are performed and make changes as needed.
  • Implement surveys to determine staff perceptions regarding independent double checks.

Drug name stem “-parin”

The drug stem “-parin” denotes heparin derivatives and low molecular weigh heparins (LMWHs) such as Lovenox (enoxaparin) and Fragmin (dalteparin). These drugs may be given subcutaneously (enoxaparin, dalteparin, and heparin) or intravenously (IV) (heparin only) based on the indication. All three medications may be dispensed in prefilled syringes and multiple-dose vials. Heparin is also available in a single-dose vial and premixed infusion bag. They are used to prevent and/or treat venous thromboembolisms (VTE), deep vein thrombosis (DVT), and pulmonary embolism and in patients who have had acute coronary syndromes. “-parin” drugs prevent clots from forming, however, they do not break down existing clots. Heparin inhibits the clotting factor thrombin while LMWH selectively inhibits Factor Xa. Activated partial thromboplastin (aPTT) must be monitored in patients who are on heparin but not on LMWHs. Enoxaparin dose adjustments are required for severe kidney disease (creatinine clearance < 30 mL/min). Dalteparin does not require an adjustment for kidney disease except in cancer patients who have decreased renal function. Bleeding is the main risk which increases if the patient is on other medications such as warfarin, direct oral anticoagulants (i.e. rivaroxaban), and nonsteroidal anti-inflammatory drugs (i.e. ibuprofen). For a “-parin” overdose, stop the drug and administer the reversal agent protamine. Another adverse effect is heparin-induced thrombocytopenia (HIT), an immune response to heparin that causes a decrease in platelet count and an increased risk of clotting. If this occurs, stop the “-parin” and replace it with a different anticoagulant such as fondaparinux, argatroban, or bivalirudin.

Safety Issues

“For Single Patient Use” Education
Insulin pens are now required by the US Food and Drug Administration (FDA) to include a warning statement, “For single patient use only” to avoid use with multiple patients. One patient was not educated on the administration technique or dosing and confused the warning to mean administer the entire contents at once. After injecting an unknown dose, the patient became unconscious and was taken to the hospital with a low blood glucose level, less than 30 mg/dL. The patient received treatment and survived. Healthcare professionals should ensure their patients understand all label warnings and dosing instructions for each medication.

Error-Prone Drug Abbreviations
Practitioners should avoid using abbreviations for drug names and instead use generic and/or brand names only. Remove abbreviations from databases, order sets, and protocols. Educate prescribers on the potential mix-ups between abbreviations particularly for the following medications: tissue plasminogen activator alteplase (tPA), tranexamic acic (TXA), tenecteplase (TNK), and  total parenteral nutrition (TPN). Prescribers should also include the drug indication in the orders to prevent confusion.

Institute for Safe Medication Practices. (2019). Nurse Advise-ERR. Retrieved from Institute for Safe Medication Practices: 

Previous issues



May: Newborn Patient Mixups November: Dangerous IV Push Medication Practices
April: Hefty Subcutaneous Doses October 2018: Tracheostomy Balloon Port
March: Epidural Antibiotic Mix Up September 2018: Errors in Clinical Education
February: Criminal Indictment August 2018: Smart Pump Low Concentration
January: Confusing Glucometer Results July 2018: Ellipta
  June 2018: Rituxan Subcutaneous vs IV
  May 2018: Nebulized Medications
  April 2018: Surgical Fires
  March 2018: Treating Hyperkalemia With Insulin
  February 2018: Barcode Errors
  January 2018: Smartpump Miscommunication



  December 2017: Ongoing Debate Texting Medical Orders
  November 2017: Dangerous Injection Practices
  October 2017: Medication Safety Assessment
  September 2017: Heparin Induced Thrombocytopenia
  August 2017: Insulin Syringe Issues
  July 2017: Texting and Patient Management
  June 2017: Verbal Order Errors
  May 2017: Unsafe Infusions & Injection Practices
  April 2017: Generic Medication Names
  March 2017: Medication Errors at Home
  February 2017: Errors in Irrigation
  January 2017: Use Technology Wisely

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