Background studies on medication errors
There are far too many medication errors on a daily basis. A study on medication errors describes that about 1.3 million people are injured annually in the United States by medication errors. The Federal Drug Administration conducted a study and found that improper dosages accounted for almost 40% of the fatalities that occurred due to medication errors. However, another less considered error is administering a medication by the wrong route. In other words, giving medication the wrong way.
The ability to truly track and investigate these occurrences can be difficult due to the lack of reporting when this occurs. However, there are some case studies which provide examples of the way this can happen. In one medication error study in England in April 2016 through November 2017, it was determined that there was 25 cases of oral liquid medications being given intravenously. Another study from the Pennsylvania Patient Safety Authority from 2004 through 2012 described 20 reports of inadvertent IV administration of oral medications, including one death.
Case study examples of oral medications given intravenously
An example from the England study was that of a 9-year-old boy who was going in for a procedure without anesthetic. The doctor prescribed an IV medication but because there was no anesthetic, the nurse assumed it was the oral form of the medication. The nurse then prepared the oral syringe and gave it to the doctor for use during the procedure. However, the nurse was not present during the procedure. The doctor attempted to administer the oral syringe intravenously but it wouldn’t fit with the intravenous connection. So the doctor switched the medication to an IV syringe and started to administer it. Realizing the error, the doctor had the child admitted and closely monitored for any adverse effects.
Another example from the Pennsylvania study included a patient that had been receiving nimodipine since admission. A few days after the patient was admitted, a nurse prepared the medication to be given through an orogastric tube. However, it was administered through the central line. The patient subsequently went into cardiac arrest. Although resuscitation efforts were undertaken, the patient passed away.
Preventing Giving Medications the Wrong Way
The studies above provide numerous reasons why these errors occur. One reason may be that the institution has weak systems in place to double-check the way medications are prescribed and administered. Another reason is that fatigued nurses can lose concentration when preparing and giving medications. It could also be that there are staff shortages which contribute to medical providers speeding through medical care and losing concentration, resulting in medication being administered incorrectly.
When these wrong route errors occur, institutions need to address the underlying problem. It could be through hiring more staff or creating policies/procedures to double and triple check medications before they are given. Our office handles cases involving medication errors, and it is tragic and extremely problematic when a patient is injured or dies from something so preventable.
