Medication Administration Errors A Serious Safety Problem

From the Patient Safety Network, Jan 2019.

Adverse Drug Event (ADE) is an injury that occurs as a result of medication error. Medication errors need to be addressed for improving patient safety, as there is a relationship between medication errors and ADEs in hospitalized patients. This article focusses on the errors in the administration of medications, which falls under the final step in the medication pathway.

Errors in medication administration can occur through failures in any of the five rights (right patient, medication, time, dose, and route). Such errors may be the result of individual-level slips and lapses but may also result from system-level failures such as understaffing, human factors problems (e.g., poor process or equipment design), and other latent conditions.

A direct observational study found that nearly 1 in 5 medication doses is administered incorrectly in the inpatient setting. IV administration errors were comparatively high with a 73% probability of at least one error. The most common type of error was the wrong time of administration, followed by omission and wrong dose, wrong preparation, or wrong administration rate (for intravenous medication).

A substantial proportion of medication administration errors occur in hospitalized children. This is due to the greater complexity of pediatric dosing (often based on weight or body surface area) which increases the risk for errors in prescribing and administration. 

Another main source of medication administration error is patients and caregivers, who are responsible for the vast majority of medication administration at home. A review of 36 studies on caregiver medication errors found error rates ranging from 2%–33%, with dosage errors, omissions, and wrong medication the most common types of administration errors. Low health literacy, poor provider-patient communication, and absence of health literacy universal precautions contribute to self- and caregiver medication errors.


In inpatient settings, interventions to prevent medication administration errors include use of technology such as barcoding for medications and patients, smart infusion pumps for intravenous administration, single-use medication packages, and package design features such as Tall Man lettering. 

Because interruptions during the medication administration process are common and associated with increased risk and severity of errors (even after controlling for nurse and hospital characteristics), minimizing interruptions during the medication administration process has also been a strong focus for error reduction. However, few of these interventions is likely to be successful in isolation, and efforts to improve safe medication use must also focus on transitions to home, primary care, and patient and caregiver understanding and administration of medications.

Barcode medication administration (BCMA) technology can essentially eliminate wrong patient, medication, and dose errors in inpatient settings. Studies have found a 41% reduction in errors and a 51% decrease in potential adverse drug events. Timing errors were also reduced by 27% in this institution.

Although BCMA reduces the opportunity for error by using barcode labeling of patients, medications, and medical records to electronically link the right dose of the right medication to the right patient at the right time, it is subject to a number of usability issues and workarounds that can reduce its effectiveness in practice. Users may encounter blockades in the BCMA workflow, for example, when the patient’s armband is not readable, the medication is not labeled or not in the system, or the scanning equipment malfunctions. A Dutch study in four hospitals found nurses used workarounds to solve BCMA workflow blockades in more than two-thirds of medication administrations. These workarounds were associated with a threefold higher risk of medication error. 

Although smart infusion pumps offer numerous safety advantages, they are also prone to implementation and human factors problems, such as difficult user interfaces and complex programming requirements that create the opportunity for serious errors.

Interventions to decrease nursing interruptions during medication administration were mildly successful and had limited acceptability and sustainability. Many patients and family members find it difficult to understand their medication regimen hence interventions should focus on improving their communication and understanding.

Experts on medication administration errors note that progress in the field is hindered by a lack of consensus on operational definitions used to classify medication administration errors, along with a wide variation in measurement strategies. Furthermore, the steps in the medication pathway are complex and interconnected. Substantial improvements in medication safety likely require a comprehensive, systems-oriented approach that integrates all aspects of the medication pathway from initial therapeutic decisions in primary, specialty, or inpatient care, to medication use in the community by patients and families.