Mitigating Risk in Medication Administration

In the spring of 2022, a former RN was convicted of criminally negligent homicide and impaired adult abuse for mistakenly administering the wrong medication that resulted in the death of a patient and was subsequently sentenced to three years of probation. The events surrounding the medication error were multifactorial, causing healthcare professionals across the country to struggle to understand how the nurse was criminally charged and found guilty. This was eye-opening for many, causing nurses and facilities to dive deep into reviewing medication administration practices, errors, and safety.

Here we are a year later.  We all know medication errors can and do happen, even among competent nurses practicing in facilities that support safe practice and just culture. Whether you are a nurse or an administrator, you play an important role in medication safety. 

Nurses, it is easy to become complacent with medication administration. You administer countless medications every day and it becomes routine. However, medication errors can have long-lasting consequences. It is crucial to maintain the standard of care when administering medications. Remember that you are the final checkpoint before the resident receives the medication. 

Always follow the “7 Rights” of medication administration: 

  • Right Patient
  • Right Drug 
  • Right Dose
  • Right Time
  • Right Route
  • Right Reason 
  • Right Documentation

Ensure best practices when administering medications. Avoid interruptions and distractions. Contact the provider with any questions or concerns. Complete medication reconciliation when indicated and check orders frequently. Include pertinent communication on medications in handoff report. If a medication error does occur, make sure to notify the provider, your supervisor and complete an event report. 

Administrators, ensure that the “7 Rights” of medication administration are being adhered to in your facility. Review your policies and procedures to make certain that they support medication safety. Evaluate medication administration practices. Are your nurses being interrupted or distracted when giving medications? What actions can you take to help decrease these interruptions and distractions? Review your root cause analysis (RCA) process to ensure that you are capturing the underlying process and system issues that allowed the contributing factors to culminate in the medication error.

Medication Safety Week serves as a reminder of the importance of continuously reviewing processes and looking for opportunities to improve practice and decrease harm. By working together, nurses and administrators can support safe medication administration practices and ultimately improve practice and decrease risk.