Medication Errors


Response To:
Forensic Nursing Chronicles: August 2007
Medication Errors

One of the hospitals that I work in is almost all computerized from charting to using a handheld for medication administration. Most physician orders are entered via the computer.
Last week when I was doing hemodialysis on a pt, I saw an order Gentamycin 80 mg IP x 1. To me it was very clear. 80 mg of gent was to be administered intraperitineal by the peritoneal dialysis nurse. (The pt was admitted for peritonitis, and was switching over to hemodialysis). I notified the PD nurse. Later on that day I received a call from the nurse taking care of the patient, informing me that she gave the medication IV, the way it was sent from the pharmacy. The only way the error was picked up was the PD nurse called the primary nurse to make sure that the gent was there when she arrived to instill it into the PD catheter.
Medication errors continue to occur. Just because it came that way from pharmacy didn’t mean that it was right. If the order is unclear to the nurse, the physician should be called to clarify the order, or perhaps the physician could write in the order “Attention PD nurse”. These are 2 simple ways to clarify the order. Everyone needs to work together to prevent medication errors from occurring. There have been countless medication errors that have cost lives.



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