Did you know that Medication errors are the 3rd leading cause of death in the United States – right behind heart disease and cancer?

Med errors account for more than 250,000 US deaths every year. Medications save lives every day, but unfortunately, these same medications can also hurt our patients if given inappropriately.

Now, most nursing medication errors don’t actually kill our patients, but they do increase morbidity, increase hospital admissions and length of stay, as well as decrease the quality of life of our patients.

As nurses administer almost all of the medications within the hospital, this means that nurses are on the front lines and will be responsible for causing or preventing these nursing medication errors from occurring.

While nurses are not the ordering Provider, it takes a team of nurses, doctors, pharmacists, and patients to decrease these med errors from occurring.

1. Nitro Paste

There’s a reason that Nitropaste only seems to be good for one thing… causing headaches! One of the reasons that Nitropaste doesn’t work well sometimes is due to medication errors in administration!

If you’re anything like I was as a new grad – you may have been taught to squirt put a thin line of nitro-paste to the ½ inch or 1-inch mark (whichever was ordered by the Provider).

This leaves a good amount of paste leftover in the Nitrobid individual packet. What some nurses fail to realize is that this is incorrect dosing!

Each individual packet of nitrobid 2% is usually preloaded (pun intended) with 1 gram or about 1 square inch of ointment. So if the provider orders ½ inch, squirt out half the packet on the application paper, or squirt the whole thing out if 1 inch is ordered.

Now you might be saying “OK, but underdosing of Nitropaste isn’t exactly killing my patient”. But you see – it can! Nitroglycerin is a SUPER important medication when treating acute coronary syndrome (i.e. heart attacks!).

If the patient has a blocked coronary artery, nitro will dilate those arteries, improve blood flow around the obstruction, and can lead to saved cardiac tissue and potentially also saving a patient’s life!

It is also very helpful for decreasing preload and afterload in your CHF patients – so it is important to make sure the patient is receiving the correct dose!

2. Ceftriaxone and Lactated Ringer’s

Intravenous medication drips are very common within the hospital – especially IV fluids, antibiotics, and even critical drips within the ICU.

Oftentimes our patients will have IV fluids running as primary, and they may also have secondary IV pushes or IV antibiotics.

This really isn’t an issue with Normal Saline, as just about every drug is compatible with NSS.

However, sometimes Lactated Ringer’s (LR) or another fluid is ordered instead. Don’t give ceftriaxone (Rocephin) with IV LR, as this can form precipitates that can harm the patient.

This is because there is calcium within the LR, and Ceftriaxone + Calcium = bad! These precipitates can cause damage to your kidneys, lungs, or gallbladder.

This can be missed in the ED where many nurses have to mix their own antibiotics and hang it secondary to whatever fluid is running. If this is LR – this can lead to issues as above.

This is just another example of how ER nurses need to be hypervigilant about preventing medication errors like this from occurring – while simultaneously managing life-threatening emergencies of their patients.

Also check out: Intravenous Fluids: Types of IV Fluids

3. Paralytic Before Sedation

Rapid Sequence Intubation (RSI) is the term used to define the methods taken to intubate a patient who is awake (for now).

Considering we’re about to stick a tube down their trachea and breathe for them – this requires sedation!

To prevent the body from fighting against the intubation, this requires medication to paralyze them – a paralytic.

During RSI, there is a specific sequence that must be followed.

You must ALWAYS GIVE SEDATION BEFORE THE PARALYTIC.

Why you ask? Well.. isn’t it obvious? If you paralyze someone before knocking them out – they are going to be TERRIFIED.

They won’t be able to breathe or move, and will be aware of the whole ordeal… So no – this won’t kill the patient, but this nursing medication error will make the whole process much more traumatic, and the patient can remember the whole thing when they wake up.

Common IV sedatives (Induction agents) include: etomidate, midazolam, ketamine, fentanyl, propofol, thiopental.

Common IV paralytics include: succinylcholine, rocuronium, vecuronium.

4. IV Insulin

It doesn’t take long working as a nurse to realize how COMMON diabetes is in hospitalized patients.

This is because uncontrolled diabetes eats away at basically every body system that you have. Your kidneys fail, your nerves are destroyed, your eyes go bad, and your arteries clog up!

Diabetics often come in for Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic State (HHS), or a patient may just need IV insulin for hyperkalemia (to push the K+ back into the cells).

Insulin is usually given SubQ, so some nurses may not be used to giving it through the IV. Those SubQ insulin needles don’t hook up to a needleless IV system – so what do you do?

Some facilities have special adapters, but honestly, the EASIEST way to do this is to draw the insulin up in your normal Subcutaneous syringe anyway. This will usually be 5-10 units. VERIFY this dose with other nurses – most facilities will require this.

Then, take a sterile NS flush, squirt half out, pull back on the syringe to make room, and squirt the insulin into the syringe. Essentially you’ve just diluted the insulin with ~5mL of saline.

Don’t set down the syringe – label it per facility protocol and give it to the patient the same way as any other IV push medication.

This may seem simple to some, but many nurses draw up the insulin in a regular 3mL syringe. I’ve seen nursing medication errors occur, and sometimes the patients are given up to 10x the ordered dose.

This obviously leads to hypoglycemia and a need for close monitoring. Worst case – this med error can lead to death, and there have been accidental deaths due to insulin overdoses.

  CLINICAL TIP

As a side note, when verifying ANY high-risk medication, make sure you look at the syringe AND the vial. I once had a nurse ask me to verify their 1mL (5,000u) subQ heparin dose. Turns out she had actually drawn up 1mL of INSULIN LISPRO! That’s 100 units! MUCH higher than most can tolerate. This med error was avoided by being diligent about verifying both the syringe amount and the vial.

5. Sound Alike – Look Alike

You may have heard about this , but a nurse in Tennessee had accidentally killed a patient when she administered VECURONIUM instead of VERSED.

This was apparently ordered to calm the patient down at MRI, so the nurse grabbed it out of the accu-dose, had overridden the medication, and administered the paralytic to the patient at CT.

Now – there are MANY nursing errors in this scenario, so let’s talk about them.

Overriding the Accudose System

This is usually a major no-no on the floors, but in the ED this is common for Pain meds, Zofran, Ativan, etc.

In the ED, they don’t always have the luxury of waiting for the pharmacy to verify medications, and some systems won’t even have the pharmacist verify ED physician orders.

If you absolutely HAVE to override, make sure you are hypervigilant about which medication you are pulling out, reconstituting, etc.

If you are unsure of a medication – ASK for help! You shouldn’t be giving a medication that you don’t know about anyway.

Always know the intended use, appropriate dosing, and potential side effects to monitor for! There are many sound-alike-look-alike drugs, and it can be common to make these nursing med errors if you aren’t careful!

Appropriate Monitoring

Monitoring the patient is an essential aspect of appropriate nursing management. As nurses, you are at the bedside and will be the first ones to notice a change in a patient’s status.

Monitoring is especially important after the administration of ANY IV medication, but especially high-risk meds like IV narcotics or sedatives.

This nurse was going to give IV versed to a patient at MRI. This patient was NOT hooked up to the monitor, the nurse had injected the medication and reportedly left back to the ER.

If you are giving IV versed, you should always have your patient on a monitor – at the least a pulse ox machine. Because she had given VECURONIUM instead of versed, her patient was paralyzed and couldn’t breathe – causing her suffocation in the MRI machine.

Appropriate monitoring of the patient, even after administering the wrong medication, would have saved the patient’s life.

6. IV Haldol

Speaking of monitoring, it is also necessary to have cardiac monitor during and after administration of certain medications.

This is because some medications can cause arrhythmias, and you want to be able to immediately identify them and recognize the need for rapid action.

Haldol can be given IV due to agitation or dementia, and sometimes for nausea. Unfortunately, this medication is high-risk for cardiac arrhythmias by increasing QT, predisposing the patient to PVCs, VTACH, Torsades, and even VFIB.

It also is worth noting that Haldol is technically to be avoided in cases of dementia-related agitation due to an increased risk of sudden death.

While our options are limited and Haldol may still need to be given, appropriate measures including cardiac monitoring should be used, at least when given IV.

Also check out:

• VTACH + VFIB | A Nurse’s Guide to Ventricular Arrhythmias
• “How to Read an EKG Rhythm Strip

7. IV Push Not IV Slam

Giving IV push medications is very common in the hospital: Zofran, IV narcotics, Toradol, and Lasix (among many others).

Nurses can be busy, so this can tempt us to quickly give the medication and immediately move on to the next task.

However, sometimes medications that are given too fast can cause unpleasant side effects for the patient, some even disastrous.

Dilaudid

Dilaudid (hydromorphone) is a common IV narcotic given for pain.

This is the “heavy hitter”, and is approximately 7 times stronger than morphine.

Dilaudid should be given slowly over 2-3 minutes.

Administering Dilaudid more rapidly has been associated with increased side effects, specifically respiratory depression and hypotension.

This is true for other IV narcotics as well like morphine and fentanyl.

As a quick tip, you can dilute the dilaudid in 50-100ml of NS and then administer it slowly over 10-15 minutes.

Reglan

IV Reglan (metoclopramide) can be given IVP in doses ≤ 10mg undiluted over 1-2 minutes.

If pushed too fast, this can cause an intense but short-lived feeling of anxiety and restlessness, followed by a period of drowsiness.

This is very common with Reglan, especially in younger females!

A small dose of Benadryl is often ordered to treat the restlessness, but note this will increase the drowsiness experienced afterward.

Be on the lookout for true dystonic reactions, characterized by involuntary contractions of the muscle of the body.

Cardiac Medicationss

Cardiac medications like Lopressor (metoprolol) and Cardizem (diltiazem) should be pushed slowly in order to prevent adverse events from occurring.

Side effects include bradycardia and/or hypotension.

Lopressor should be pushed over 2-5 minutes and Cardizem over 2 minutes.

Dexamethasone

Doses of IV dexamethasone 4-10mg are often given undiluted over <1 minute.

However, rapid administration is associated with perineal irritation.

Patients will tell you “my crotch is on fire!”.

This can even happen with slow administration, so warn the patient that this is a possible side effect, is short-lived, and will go away on its own.

Its recommended to dilute it in a 50ml bag and run it over 5-15 minutes to minimize this occurrence.

Also Check out: Adverse Drug Reactions Nurses Need to Know

8. Proper IM Location

When I was a nurse I was taught to inject most IM medications >1mL in the butt. However, where I was injecting in the butt wasn’t really specified.

Many nurses just shoot for the middle of the buttock (dorsogluteal), but this can actually cause all sorts of injury to the patient.

While not super common, injecting in the dorsogluteal region can lead to skin and tissue trauma, muscle fibrosis and contracture, hematoma, nerve palsy, paralysis, and infection. 

Instead, these medications should be given in the ventrogluteal site.

The Deltoid muscle is an easy location for all injections 1-2mL in most adults. However, even 1 mL can be very painful in the deltoid depending on the patient.

This is also not a recommended site if giving repeat injections, as the surface area of the muscle is not very high.

An important fact to know about intramuscular injections is that the vastus lateralis (the side of the thigh) actually offers the quickest absorption.

This means that if you have a patient come in for a severe anaphylactic reaction – your best bet is to inject the epinephrine in the thigh as opposed to the arm.

9. Broad Before Narrow

Antibiotics are given ALL the time within the hospital.

Patients may be septic and need immediate treatment including multiple IV antibiotics.

Some antibiotics have a very broad spectrum – eaning they kill all sorts of bacteria. Others have a narrow spectrum, meaning they kill fewer bugs.

You always want to make sure to hang the broad-spectrum antibiotic first. This ensures that the antibiotic most-likely to help will be given first.

One common mistake is nurses think Vancomycin is broad-spectrum because it is a “heavy hitter”, but Vancomycin is actually narrow!

Vancomycin mainly only covers gram-positive organisms!

This means unless the bacteria is actually MRSA or another Gram-positive infection, Vancomycin is less likely to help. PLUS it takes a while to infuse anyway (like 1.5-2 hours).

The best decision in sepsis is to hang the broad-spectrum antibiotic first. Common examples of broad-spectrum antibiotics include:

• Ceftriaxone (Rocephin)
• Cefepime
• Pipericillin-Tazobactam (Zosyn)
• Imipenem
• Ampicillin

And there you have it! With great power comes great responsibility. Nurses are responsible for administering life-saving medications, but these medications can also hurt if given inappropriately.

We must be vigilant in avoiding nursing medication errors and improve our patient-outcomes.

Do you know of any other common nursing medicaiton errors? Let us know in the comments below!

You may also like:

• Adverse Drug Reactions Nurses Need to Know
• 10 Nursing Hacks Every ER Nurse Should Know
• 20 Tips for New Nurses In the Hospital
• Calling the Doctor – Giving Nurse to Provider Report
• STEMI & NSTEMI: A Nurse’s Comprehensive Guide