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 Errors and Just Culture

Medication administration is a fundamental skill learned in nursing school. Part of that process involves making mistakes. Instructors and staff that are mentoring students need to respond fairly and compassionately to students and health professionals who make a mistake. Nursing school curriculums should integrate a Just Culture philosophy including the knowledge, skills, and attitudes required to understand human fallibility and the risk of medication errors. Nursing faculty and students need to understand why medication errors happen and how to reduce their occurrence. They need to be comfortable asking for help when gaps in knowledge occur and reporting errors without fear of reprisal.
Recommendations for nursing faculty include:
  • Define and create a Just Culture in your nursing curriculum
  • Incorporate safety- and quality-focused components into the nursing curricula beginning with the first semester
  • Establish a second victim response team within the nursing program

Maximizing ADC Medication Removal and Restocking Accuracy

Many automated dispensindg cabinets (ADCs) utilize barcode scanning technology with stocking and/or removal of medications. This functionality helps promote the accurate placement of medications when stocking/restocking the cabinet and confirms the correct medication has been removed prior to administration to the patient. Some hospitals utilize barcode scanning when removing medications from the ADC to decrease the accidental removal of the wrong drug from the ADC. This has been successful in reducing the number of errors upstream before reaching the patient. However, this functionality may not be used across an entire health system. Some facilities use barcode scanning at the bedside instead.
Stocking errors happen when a drug is scanned, the ADC drawer is opened, and a different drug that looks similar, is accidently placed in the same drawer. The mix up typically occurs during the drug selection process in the pharmacy. Another issue occurs when nurses return medications (non-controlled substances) with intact packaging to the ADC without having to scan the barcode on the medications they restock.
Strategies to reduce errors upstream in the pharmacy include:
  • Select strips of tablets or unopened cartons containing multiple prefilled syringes or vials when gathering medications to stock the ADC. These should contain the same product, reducing the risk of error despite scanning only one of the products.
  • When more than one strip of tablets or carton of prefilled syringes or vials is needed to stock/restock the ADC, keep them together with a rubber band immediately after removing them from the pharmacy storage bin and before placing them on the counter/cart (to avoid mixing them up with different medications).
  • Pharmacists should visually inspect each strip of tablets or unopened carton during the verification process when performing independent double checks of the ADC restock medications prior to distribution. Barcode scanning is also recommended upon selection of medications in the pharmacy for stocking/restocking ADCs to confirm that the medication for distribution to the ADC matches the medication listed on the ADC fill report.
  • Refer to a stocking list (ADC fill report) when replenishing the ADCs, checking off each medication as it is loaded into the ADC. If any medication remains unstocked and/or unchecked, investigate for an error.
  • Use individual, locked-lidded pockets for medication storage in ADCs and avoid use of open matrix drawers and open storage in towers and refrigerated units. Never store high-alert medications in open matrix drawers. Use them only for storage of non-prescription medications and saline flushes.
  • Enable the functionality that requires nurses to scan the barcode on the medication prior to restocking in the ADC. Non-controlled medications should be returned to a locked-lidded pocket, not a matrix drawer, and only if barcode scanning is required.

Safety Issues

Confusion between Cecostomy and Gastrostomy
Cecostomies may be placed to irrigate the small intestine and prevent or manage constipation. Gastrostomy tubes (G-tubes) are inserted to deliver nutrition directly to the stomach. These devices may  use “button” technology, a low profile device that is anchored with a balloon to the abdominal wall. The button devices are not visible under clothing and include brands such as Mic-Key and the MiniOne. Medications should not be administered through a cecostomy as they will not be absorbed. G-tubes should be used instead. The button devices may be confused when generic extension tubing sets are added to the ports. As a preventive measure, ENFit extension sets are available for use with both the Mic-Key gastrostomy buttons and the MiniOne devices. To prevent mix-ups, medications should be provided by the pharmacy in ENFit syringes, which can then be used with ENFit extension sets. Use regular extension tubing with cecostomy buttons as these will not connect with ENFit syringes, preventing misconnections and errors in drug administration via the wrong tube.
Barcode Scans Wrong Drug
There have been reports of McKesson’s levetiracetam 250 mg (an anticonvulsant) unit dose blister package that has a barcode that scans as naproxen 500 mg (a nonsteroidal anti-inflammatory drug). The barcodes on one side of levetiracetam scan properly, but the barcodes on the other side indicate it is naproxen. If the drug is placed in a bin assigned to naproxen in the ADC, it may be seleted incorrectly and given to a patient in error. In addition, if the mislabeled product is stored with levetiracetam in the ADC and retrieved for a patient prescribed levetiracetam, the drug alert message may appear when scanning the product, leading to confusion and a potential delay in care. McKesson has been notified and the company is investigating the issue.
MicroVault Cover
Prefilled opioid syringes from Fresenius Kabi are packaged in a MicroVault cover with a tamper evident seal and hard plastic packaging that can help prevent diversion. Nurses and other practitioners must properly open these packages or they might damage the syringe. There have been reports of the plungers coming out from morphine syringes when the seal is broken and the MicroVault is opened. Opening the MicroVault cap by snapping it off can dislodge the plunger. Instead the cap should be twisted off and not snapped off.
Parenteral and Enteral Nutrition
The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends using a 1.2 micron in-line filter for parenteral nutrition (PN) and lipid injectable emulsions (ILE). This helps decrease the confusion and errors that can occur when using two separate filters with different pore sizes. Simplification of the filtering process may improve compliance for filter use with PN administration.

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

Previous issues


May 2021: Transdermal Patch  
April 2021: Medication Safety Officer  
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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