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Have you ever made a drug error?

  • Comments (4)

The dose was ten times larger than had been prescribed and the baby died. A registrar had prescribed 5ml of sodium chloride but the baby was wrongly given 50ml.

This case is a timely reminder of how mistakes can occur with sometimes devastating consequences.

Clear policies and procedures govern the administration of drugs yet nurses - like other health professionals who prescribe and administer medicines - sometimes do make errors, and near misses. These occur for lots of reasons; nurses are rushing, they get distracted, don’t check name bands, they fail to sign prescriptions or look up a drug in the BNF if they haven’t given it before. Ultimately they occur because health professionals are human beings, and human beings make mistakes from time to time. However, while mistakes will never be completely eradicated, practitioners must do what they can to minimize the risk.

The most frequently cited reason for giving the wrong dose of a drug is calculation error.

Nurses must be numerate to administer drugs safely. They have to be able to calculate doses and with increasingly complex drug regimens they need to be confident that their calculations are accurate.

Anyone administering medicines needs to be regularly reminded of what constitutes safe and effective practice but this is easy to say, less easy to make a reality when staffing is at a premium and opportunities for study leave is limited.

Nursing Times Learning has recognised these challenges and has launched an online unit on Drug Calculations in Practice. After studying it you will be able to:

  • Explain different units of measurements used for medicine dosages
  • Calculate dosages for medicines in tablet and capsule form
  • Calculate dosages for medicines for the weight of a patient
  • Calculate dosages for medicines in suspension or solution.
  • Calculate the administration rate for continuous IV infusions of medicines and fluids
  • Recognise incorrect dosages of medicines and know how to ensure patient safety

On 26 October at 4pm we are hosting a FREE clinical chat with the author of the learning unit, Kerri Wright, senior lecturer at University of Greenwich and author of Drug Calculations for Nurses, published by Palgrave. She will be joined by Philip Marini, retired headmaster and Ofsted registered inspector who worked for Brighton and Sussex University Hospital Trust and Western Sussex Hospitals NHS Trust, providing drug administration numeracy materials for newly appointed nurses and healthcare assistants.

If you aren’t able to take part in the webchat you can email questions to eileen.shepherd@emap.com or tweet them to @eileenshepherd then read the transcript later, but we hope as many of you as possible will join in to discuss this important issue.

Visit our Medicines Management page.

Participating in NT Clinical Chats can contribute to you CPD. How to get the most out of Clinical Chats:

  • Look at the topic in advance of the chat and plan questions you would like to ask
  • Participate in the chat by posting questions or comments
  • Download the transcript after the chat as evidence of your participation. This will be available here after the webchat.

Write a reflection on what you have learned and how you could use this information in clinical practice, to store in your portfolio.

  • Comments (4)

Readers' comments (4)

  • Anonymous

    you just have to go to the nmc site to see how many drug errors occur although I don't know why some are reported to the nmc and others get dealt with in-house or some are not dealt with at all

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  • Anonymous

    Yes I have made a drug error, and reported it immediately that I realized (and I was mortified). Luckily for the patient there was no harm to them. One factor is the pressure to carry out a drug round in a timely manner which dissuades one from stopping and looking up the BNF or double checking all the elements one needs to (all the rights). Taking too long and having too short a time between doses is a drug error in itself. Another factor is interruptions with more demands on the time, skills and knowledge of the qualified staff. None of the above is acceptable as excuses and I have to manage these factors to ensure errors do not occur. In answer to the comment above - some people do not learn from their mistakes, or even acknowledge them. With some the drug error is a symptom of other problems with their ability to practice as a nurse. It is those people, who are a danger to their patients, colleagues and the profession who should be reported to the NMC.

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  • I have just been given notice of an excellent guide from the NHS Patient Safety First that addresses the need to look at human factors that contribute to errors.
    It hopes to help change the culture of blame that inhibits learning from mistakes, with case studies to illustrate the points they are making.
    If only managers and staff would implement these approaches, it would stop the need for our support and information website - www.suspension-nhs.org! One can hope.
    Julie Fagan founder member Campaign Against Unnecessary Suspensions and Exclusions UK CAUSE

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  • Anonymous

    I have also made an error. No harm came to the patient as it was picked up by the second nurse checking. I was placed on the capability and underwent iv additives/drug administration training in the clinical skills department. This knocked my confidence and I delegated iv's after my experience to other members of staff in fear of repeating the mistake. This caused problems as members of the small team felt that I wasn't a team player, I received negative feedback from management that I wasn't at the level that I was expected to be with my years of experience. I was moved within the unit to another role which required technical training however was structured and a competency programme meant that I could "in theory" meet my objectives. Throughout the period I had ongoing personal problems and health problems arose and the pressure I felt was immense. It is stressful but you have to put things into perspective and apply root cause analysis approach to the incident breaking down the events and also taking into account personal factors such as stress, tiredness from working long days, personal issues. Reflect on everything, learn from it and move on. But most importantly . . . How would you feel if it was your relative, child who was on the receiving end? The medicines management guidelines are structured and supportive and only recently have been customised in certain trusts. At the time in my instance I was preparing iv's in an area that was not compliant. The area designated was next to a phone, in front of a computer and next to the nurses station in full view of patients. This has now changed, the refurbishment which has taken place throughout the trust in all ward areas means that you have a clean, quiet, suitable area which pharmacists, managers have in theory designed.

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