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.

Newborn Patient Mix-ups

Newborn babies are at an increased risk of errors related to patient mix-ups within the hospital setting. Multiple factors that contribute to wrong-patient errors within this population include:
  • Newborns cannot confirm the patient identification process since they cannot speak.
  • Infants are difficult to distinguish from one another.
  • Many newborns aren’t given names right away.
  • Last names, medical record numbers, and birth dates are very similar to mother and other babies born within the same timeframe.
Hospitals may assign a temporary first name, such as Babyboy/Babygirl, Boy/Girl, or BB/BG with the mother’s last name to identify infants. This results in patients with similar identifiers such as infants with the same last names and non-unique first names. Twins and other multiple birth newborns are at an even higher risk since they share the same birthdate, gender, and last name. They are typically distinguished by a letter or number (i.e Babyboy1/Babyboy2) that could be overlooked. In addition, medical record numbers are assigned by numerical order and differ by only one digit between siblings. Infants in the neonatal intensive care units (NICUs) are at an increased risk for errors given the large numbers of medications and treatments they receive – one out of four mistakes results from misidentification. Numerous errors also occur when the temporary name is changed to a permanent name in the electronic health record (EHR) before discharge to prepare the birth certificate. In addition, long temporary names might be shortened in the EHR, on name bracelets, and on medication administration records (MARs) leading to confusion between mother and newborn and/or multiple births.

Errors related to patient mix-ups include:
  • Medication errors
  • Wrong feedings of breastmilk
  • Wrong patient diagnostic tests, procedures or surgery
  • Order entry and documentation errors
  • Misidentification of diagnostic results
  • Infants switched at birth and discharged to the wrong parents
The Joint Commission (TJC) recommends using a more distinct temporary newborn naming system and switching to the infant’s given name as soon as it has been selected by the parents. TJC recommends the following strategies to decrease identification errors:
  • Use mother’s first and last name and the baby’s gender (i.e. “Jones, Sara Girl”) – this recommendation comes with great criticism as this naming system results in the mother and newborn’s names being too similar and if the name is truncated in the EHR, the names of the mother and child appear to be identical
  • Use at least two patient identifiers when providing patient care
  • Place identification bands and barcoding on two body sites such as wrist and ankle
  • Alert staff with signs if newborns have similar names

Drug name stem “-gliptin”

The suffix “-gliptin” denotes dipeptidyl peptidase 4 (DPP-4) inhibitors, a class of oral antidiabetic drugs that lower blood glucose by inhibiting DPP-4 and improving insulin secretion. These drugs are taken orally once a day with or without food. They are not typically used for initial treatment but may be used as monotherapy for patients with chronic kidney disease or with other antidiabetic medications.
DDP-4 Inhibitors (-“gliptin”) available in the US:
  • Alogliptin (Nesina) – combination drugs include alogliptin/metformin (Kazano) and alogliptin/pioglitazone (Oseni)
  • Linagliptin (Tradjenta) – combination drugs include linagliptin/empagliflozin (Glyxambi) and linagliptin/metformin (Jentadueto, Jentadueto XR)
  • Saxagliptin (Onglyza) – combination drugs include saxagliptin/metformin (Kombiglyze XR) and saxagliptin/dapagliflozin (Qtern)
  • Sitagliptin (Januvia) – combination drugs include sitagliptin/metformin (Janumet, Janumet XR) and sitagliptin/ertugliflozin (Steglujan)
Adjust dose for all -gliptins (except linagliptin) for moderate to severe renal insufficiency. Assess creatinine level prior to starting therapy and for the duration of treatment. Reduce the dose of saxagliptin in patients taking cytochrome 3A4/5 inhibitors such as antifungals (Ketoconazole), protease inhibitors (ritonavir), antibiotics (clarithromycin). Avoid rifampin, phenytoin, carbamazepine and dexamethasone in patients taking linagliptin.
Adverse effects associated with “-gliptins” include: nasopharyngitis, headache, joint pain, bullous pemphigoid, urinary tract infections, and acute pancreatitis.

Safety Issues

Insulin Pen Injector Instructions
Insulin pen needle injectors typically have two covers, an outer and inner, that must be removed before injection. Patients may not be instructed to remove two covers on their pen needles after they are discharged due to the fact that hospitals use safety needles with only one removable outer cover. If the inner cover is not removed, they will not administer the insulin they need. The Food and Drug Administration (FDA) has requested that manufacturers update the educational materials to include the need to remove the inner needle cover/cap before injection. The FDA suggests adding a warning to the label stating: “Remove both the outer cover and the inner needle cover before injection. If both the outer cover and inner needle cover are not removed before use, the medication or dose may not be injected, which may result in serious injury or death.”

Vancomycin Diluent Administered without Active Ingredient
Oral vancomycin is manufactured and distributed by CutisPharma as a kit containing a bottle of powered vancomycin and a bottle of grape-flavored diluent. The powder must be reconstituted with the diluent prior to administration. There were reports in 2016 that the diluent had been administered alone without the powdered vancomycin mixed in. CutisPharma had changed the label to emphasize “Diluent” on the diluent label and “Powder” on the vancomycin powder bottle. This product was discontinued in 2018 following the approval of Firvanq (vancomycin). The new product label did not emphasize “Powder” as it had on the previous label. There have been new reports of Firvanq diluent being administered alone. If your hospital stocks the new Firvanq kit in the emergency department or other areas, keep the bottles together in their carton until the product is reconstituted. The diluent bottle does not have a barcode which will help prevent it from being scanned by the medication administration system.

Epinephrine Autoinjectors
Epinephrine, used to treat anaphylactic allergic reactions, is dosed by weight, not based on whether the patient is an adult or child. The generic epinephrine autoinjector labels do not use “Jr” for the 0.15 mg dose. “Jr” is part of the trademark name for epinephrine. Staff should be made aware that the generic autoinjectors will only list the strength, 0.3 mg or 0.15 mg and not “Jr”. Young patients who weigh 30 kg or more should use a 0.3 mg injector. Patients weighing between 15 to 30 kg should use the 0.15 mg injector.

Patient Controlled Analgesia (PCA) Pump Keys Online
Keys that unlock CADD-Solis and CareFusion Alaris Medley PCA pumps are available for purchase online from Walmart, eBay and other websites. Other PCA lockboxes (BD Alaris, Hospira Sapphire) can be opened with items found on the patient care unit. Therefore, opioids contained within these PCA pumps are unsecure. Additional security measures such as software codes to activate the locking mechanism should be employed to ensure the safety of these medications. 


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

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