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.

Dangerous IV Push Medication Practices

Earlier this year, the Institute for Safe Medication Practices (ISMP) conducted a follow-up survey to three prior surveys that uncovered many dangerous intravenous (IV) push medication administration practices among clinicians. While the latest survey found a decrease in some of the risky practices, many are still in use and may be related to drug shortages, system issues, and teaching methods that maintain these unsafe habits. Prior surveys found the following:
  • Long delays in dispensing pharmacy-prepared IV solutions
  • Preparation of IV medications at the bedside
  • Use of prefilled medication syringes or cartridges as vials to withdraw the drug into another syringe prior to administration
  • Dilution of medications that were dispensed in ready-to-administer forms
  • Inappropriate use of prefilled normal saline flush syringes to dilute IV push medications that may result in mislabeled syringes
The latest survey gathered information on the impact of ongoing drug shortages and teaching methods on current IV push medication practices. Survey respondents included nurses, advance practice nurses, nurse anesthetists, anesthesiologists, and physicians, mostly working in inpatient settings. Survey findings are summarized below.

Ready-to-Administer Syringes
Most participants (75%) receive half or fewer IV push medications in pharmacy-prepared or commercially available ready-to-administer syringes. The most common medications not provided in ready-to-administer syringes include:
Antiemetics Antibiotics with short stability Metoprolol
Antipsychotics Opioids Furosemide
Benzodiazepines Pantoprazole  
These medications are available in a prefilled syringe; however, supply has been limited.

Withdrawing Medications from a Prefilled Syringe and Transferring to Another
Over 65% of respondents reported withdrawing drugs from a prefilled syringe or cartridge and filling another syringe to administer part or all of an IV push medication dose. The most common reasons for this practice include:
  • To dilute the drug
  • No designated syringe (cartridge) holder
  • How they were taught
  • Difficult to read syringe dose increments
  • Syringe does not have a needleless connector or removable needle
  • Drug shortage (administer partial dose to conserve a limited supply of a drug)
  • Filter medications in a cracked syringe or one containing particulate matter

The majority of survey participants (84%) reported that they have further diluted adult IV push medications prior to administration. Dilution was not as frequent with pharmacy-dispensed syringes containing patient-specific doses. The most commonly diluted medications were opioids, anxiolytics/antipsychotics, and antiemetics, irrespective of the container in which it was dispensed. Most participants who dilute IV push medications used a prefilled 0.9% sodium chloride (saline) flush syringe that was either prepared commercially or by the pharmacy. In addition, most responders indicated that they did not relabel the flush syringe. This practice has increased over the last several years and may be due to a shortage of saline vials at the time of the survey. Reasons for drug dilution include:
  • To administer the drug slowly
  • To limit patient pain
  • To decrease extravasation risk
  • To accurately measure small volume doses
  • To comply with drug-specific requirements and facility policies
  • To follow recommendations in drug references
  • Due to prior education and training

Approximately 50% of respondents stated they always label IV push medications that are prepared away from the patient’s bedside.  Almost 30% stated they rarely or never label syringes. Many felt that labeling was not needed if they prepared just one medication or one syringe. A few stated they could distinguish between multiple syringes without a label by checking the volume of medication or the size of the syringe; by different needles, caps, or medication colors; by placement on a tray or sterile field; or by carrying syringes in different hands or pockets.

Drug Shortage
Due to current drug shortages, respondents agreed they were:
  • Giving more medications via IV push that were previously given as infusions (i.e. antibiotics, antiemetics, proton pump inhibitors)
  • Required to prepare more IV push medications at the bedside (or wait longer for pharmacy to prepare and dispense medications)
  • Provided with IV push drugs in unfamiliar concentrations and packages (or in volumes greater than needed for each dose)
  • Given fewer prefilled, ready-to-administer syringes than previously (in the correct concentrations or volumes)
Drug shortages may also result in delays in treatment secondary to pharmacy preparation of products that are limited in supply. Medications that are prepared in prefilled syringes are often provided in amounts greater than what is needed by the patient which may lead to drug waste.

Education and Training Around IV Push Medication Administration
Clinicians typically learn how to administer IV push medications during professional training, during their first job orientation and/or current position, from drug references, and from on-the-job experiences.

Rate of Administration
Only 60% of respondents indicated that the rate of administration of an IV push medication is included on the patient’s medication administration record. Many stated they needed to look up the rate of administration in drug references, in facility guidelines, or rely on recall. Some stated that they give all IV push medications over two to five minutes, and therefore don’t need to look up or know the specific rate for each drug. Others reported that they administer all IV push medications in less than two minutes. The majority of respondent use a clock, watch, phone, or other timing device to help control the speed of IV push drug administration. Some state that they give small incremental doses frequently, and others state they apply constant pressure on the plunger.
Dangerous IV push medication administration practices have existed for decades and continue to persist today. Educators and health care administrators should ensure their students and staff are trained on the appropriate techniques for safe medication delivery.

Safety Issues

Nitroglycerin Nightmare
An inexperienced nurse on orientation administered an entire bottle of nitroglycerin to her patient. Fortunately, another nurse caught the error and removed the tablets from the patient’s mouth and the patient was not harmed. This error could be due to the “unit dose” safety initiative in which medications are delivered to nurses in unit dose packages to decrease errors. In this situation, a very small vial or bottle of medication was dispensed that contained more than one dose and the nurse assumed it was a single patient dose. Clinicians, manufacturers, and pharmacy compounders should avoid putting multiple doses in one container. However, that is not possible with nitroglycerin tablets. Nitroglycerin tablets must be dispensed in their original 25-count dark, amber glass bottle to maintain stability.

To prevent this error, program the medication administration record (MAR) and automated dispensing cabinet (ADC) screens to include instructions to administer just one tablet sublingually (additional doses as ordered), and place a warning label on the glass bottle with the same information. Another strategy is to place the nitroglycerin vial in a plastic bag with a warning label. As a general rule, inform all clinicians to call the pharmacy if they need more than three pills, vials, or other dosage forms.

Suppository Confusion
There have been several reports of mix ups between similar looking foil-wrapped suppository packages. Examples include confusion between prochlorperazine and promethazine as well as bisacodyl and acetaminophen. When possible, health care institutions should purchase suppositories from different manufacturers to avoid look-alike labels. Nurses should always scan the medication prior to administration and notify the pharmacy if products are mixed within the ADC.

Fentanyl Overdose
Following several doses of IV push morphine in the emergency department (ED), a patient was admitted and then given a 250 mcg IV push dose of fentanyl. A shortage of hydromorphone prompted a physician (unfamiliar with fentanyl dosing) to place the order. Fentanyl 250 mcg/5 mL was available as a selection on the order entry screen without a warning. Both the pharmacist who verified the order and the nurse who administered it were also unfamiliar with the appropriate dose range for fentanyl. The patient became apneic and unresponsive but was resuscitated successfully by the staff. Following this event, the hospital developed an opioid conversion chart as a guide for equivalent opioid doses. Fentanyl 250 mcg was removed as an option in the computer order entry system. A high-dose alert, “Recommend max dose of 50 mcg” was added to the fentanyl 100 mcg screen and the alert must be acknowledged when removing the drug from the ADC.

Nebulizer Mix-Up
Due to look-alike packaging, racepinephrine (Asthmanefrin) inhalation solution has been mistaken for ipratropium bromide inhalation solution. Both drugs are manufactured by the same company and had similar barcoded overwraps (green on white labeling) with generic names in small, white font. While both products are bronchodilators, their mechanisms of action differ. The company revised the racepinephrine label to reduce confusion. Scanning the barcode prior to administration will help prevent mix-ups as well.



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

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