published on
May 3, 2023

Why medication errors happen, and how to avoid them

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Care professionals
Why medication errors happen, and how to avoid them

Medication errors are a serious issue if you work in nursing homes. They can often be prevented if you make sure you’re following up-to-date guidelines.

At Florence, medication errors are the largest category of incidents our Incident Management team deals with. 

Errors in medication can range from missing signatures on MAR sheets, to reports of medication administered in error, to incidents where the wrong person receives the medication to the wrong dose being given.  

Here, we’ll talk about why medication errors happen, steps you can take to prevent errors, and how Florence can support you if you become involved in an incident. 

Why do medication errors happen?

We see medication errors occurring mainly due to distraction, the environment (such as chronically understaffed and overworked employees), or a lack of knowledge of individual patients and their medical history.

Such errors tend to fall in to the following categories...

Prescribing errors

For example, the drug choice is incorrect for the condition or the patient; or the wrong dose, route, concentration, frequency is prescribed.

Timing errors

This is when a drug is administered or prescribed at incorrect frequencies. In serious cases, this could result in toxicity or overdose (or the reverse and a lack of critical medicine given to control an illness or condition).

Omission errors

Failing to give a dose when prescribed can result in conditions not being treated/managed properly.

Incorrect dosage administration errors

Too much or too little of a medication being administered, for example, Morphine 100mg rather than Morphine 10mg despite the correct amount being prescribed on the patient prescription chart.

Wrong administration technique

or example, giving an oral drug intravenously, a subcutaneous injection via intramuscular route etc.

Incorrect preparation of a drug

For example, not adding the right dilutions, additives or solutions to ensure a drug is safe and/or effective.  

How to avoid medication errors

Given environmental pressures and human error are often the cause of errors, what can nurses do to prevent them from happening in the first place?  

1. Know the patient

Always check the patient identification band and details.  Make sure that the date of birth, allergies, pertinent blood results as well as weight, vital signs and other relevant factors are known before administering any medicine.

2. Know the drug 

Know the indications, side effects, normal dose, frequency, administration route, contraindications and compatibility of the drug.

3. Know the environment

Ask for a site induction on your first day working at a new care home, and make sure you are familiar with the layout of the care home prior to starting a medication round.  

We have multiple concerns raised to us annually around nurses who administer medications to the wrong resident as a result of not being familiar with the layout of the care home.

4. Introduce yourself

Make sure you introduce yourself to residents, particularly if your medications round is at night or the resident is asleep in bed. Surprisingly, we’re heard of a few rare incidents when a nurse did not introduce themselves and administered the medication without communication.

5. Push back on interruptions

Take your time on medication rounds and do not allow others to interrupt you unless in an emergency. Many nurses reflect in their statements to us that they felt rushed or under pressure to complete medications rounds, for a variety of reasons. 

Wear a tabard to indicate you are on medication rounds and cannot be interrupted, and reinforce the message "DO NOT DISTURB" in your actions towards colleagues. 

If you are interrupted while on a round, say “I’m on a medication round now, so I can’t help with that - please can you find someone else who can assist?” 

Or, if it’s something non-urgent that you know only you can help with, say “Because I’m doing a medication round, I can’t help right now - but I can get to it afterwards.”

Be prepared to repeat this several times to get the message through to colleagues who interrupt often. 

6. Be proactive

Maintain good communication and take action on potential problems you have identified in terms of a patient's medication or dosage.  

Although nurses are not responsible for prescribing drugs, with experience it is common to develop a deeper understanding of them. Share your knowledge or concerns with other nurses, doctors and healthcare professionals and don’t be afraid to speak out.

7. Ask questions and double check

There is nothing wrong with double checking. Ask lots of questions and seek advice and help when you feel uncertain. It's better to be safe than sorry.

8. Don’t crush medication unless instructed

NEVER crush medication unless clearly indicated in the care documentation / MAR sheet. Crushing medication will change the way it is metabolised within the body. This can cause a toxic medications effect that may be harmful to the recipient.

9. Don’t give covert medication unless instructed

NEVER give medications covertly unless indicated in the care documentation.  

10. Maintain good documentation  

Always sign for the medications given, or indicate where medication has been refused.

By consistently signing as soon as a drug is administered and never signing for a medicine not yet given, the safety of the patient is protected.

11. Keep up to date and educated

The Royal Pharmaceutical Society and the Royal College of Nursing co-produced a clear, well-defined guide to ensure the safe administration of medicines by healthcare professionals.

Keeping up to date on materials like this will help you avoid medication errors due to any outdated knowledge. Nurses should be aware of the laws, policies and protocols surrounding the safe administration of medicines stipulated by their regulatory body.

Medication errors are dangerous. But by having a culture of continuous learning, open and honest reporting and transparent, no-blame culture, we can hope to reduce the incidents of medication errors, protecting our patients and ourselves.

How Florence can help

At Florence, our Incident Management team is here to provide support and assistance to those involved in incidents on shift, including medication errors.

If you find yourself involved in a medication error incident, Florence will support you in investigating what happened. During this process, we gather statements from both you and the home, suggest actions to take, and look to close the incident to the satisfaction of all parties. 

To discuss a medication error incident, get in touch with our team on

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