Medication handling is one of those activities where small mistakes can entail great consequences. The good news; most mistakes can be avoided with mundane, scrutable tests.
Common medication handling errors – and how to prevent them
Over time, it occurs often that during hectic call-outs or interruptions can disrupt a healthcare worker’s routine. It has always been and will forever be about the right checks (person, drug, dose etc) every single time. Where possible use two identifiers (name and date of birth for example) Do not rely on memory!
Skipping documentation (or documenting later)
It is simple to say you will “do the paperwork after” but any time-delay adds confusion and increases the risk of overlap dosing. Record after giving, and if something goes awry (refusal / vomiting), capture in writing obvious notes along with your escalation policy.
Selection errors could also occur if medications end up stored loosely and unlabelled in the wrong place, or near identical packaging. Preserve medicines in their original packaging, store them properly (like a refrigerator if needed), and don’t stock up near similar names/boxes. Check expiry dates routinely. For Safe handling of medication training, visit https://www.tidaltraining.co.uk/health-and-social-care-courses/safe-handling-of-medication-training
Not checking changes to prescriptions
Without good communication between the teams, dose changes may not be seen on rounds or discontinued medications and new prescriptions can go unnoticed. Embed a robust handover process: point out the amendment, cross check changes, ensure paperwork is updated and old stock removed or isolated from opportunistic use.
Medications given PRN without clear reason
PRN (as needed) should be a familiar term but is often misinterpreted and can lead to confusion when guidance isn’t clear. Prevention: PRN protocol specifics (for specific symptoms, minimum time between doses), maximum daily dose etc. Always keep records of why it was prescribed and whether or not it helped.
Controlled drugs errors
This is an area that is most often analysed because there can be errors in count, missed signatures or not being secured securely. Maintain a standard process of double-checking, secure keys and record data at the time, not end-of-shift.
Distractions and rushing
If on a medication round, establish clear uninterrupted time to prepare (with no interruptions where possible), work in an area that allows you to remain as calm and focussed while preparing the patient’s prescription, pause if unsure. If something looks wrong – always pause and verify, further delay is better than a mistake.
The question becomes one of how to build ecosystems that identify such errors, rather than how those responsible for medication use may mistakenly handle it. Processes that are clear, open communication and regular checks keep the individual receiving meds safe as well providing more support for staff.
About Author
