Capstone Project: Medication Errors Due to Cluttered

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Medication Errors Due to Cluttered Work Environment

Medications errors due cluttered work enviroment

Medication errors are the most error types that affect patient safety. Medication errors are preventable events that may lead to patient harm McDowell, Ferner, & Ferner, 2009.

Giving a patient the wrong Medication could have adverse effects on the patient, which could also lead to death. The administration of drugs is predominately the responsibility of nurses, but drug administration is one part of the management process for medication. Medication errors could result from other aspects in the medication process like procurement, storage, selection, ordering, prescribing, and transcribing Fijn et al., 2002.

Medication errors could also be influenced by system issues, quality of prescription, staffing workload, deviation from procedures, shift patterns, and cluttered work environment.

The literature focuses more on medication errors due to prescription, selection of drugs, storage, product labeling, and education BRADY, MALONE, & Fleming, 2009.

There is little research conducted regarding errors due to a cluttered environment. This limits the information for how a cluttered environment would affect medication errors. A cluttered environment would cause medication errors as the nurse would mix up medications or administer the wrong medication to the patient. The environment would affect proper drug administration because without much attention the nurse is likely to administer to a patient medication intended for another patient. It is vital that a nurse double checks the medication been administered to the patient. This way the nurse will avoid any medication errors. This is easier said than done because nurses have to administer drugs to different patients at the same time and this makes it easy for them to mix up the medications.

Staffing workload is another major cause for medication errors. A nurse who is overworked is more likely to prescribe the wrong medication to a patient. The nurse will not be able to double check the medications, and they are more likely to administer the wrong medication. The workload will affect the nurse's concentration levels, and they might mix up the medications. Since the nurse would be rushing to complete her medication rounds they might not have the chance to confirm the drugs they administer to the patient. This could have adverse effects on the patient if not discovered early. Information overload has been found to lead to medication errors. A nurse who is given too much information regarding a patient or patients would confuse the drugs. The nurse would have a lot on their mind, and this is likely to affect their concentration when administering medication. Failure to have checks and balances could increase the medication errors. Having checks and balances provides a nurse with a means to identify and confirm they have administered the correct medications. In case they discover the fault early it could be easy to remedy the situation than if the fault is not discovered.

In the situation, the nurse was rushing to administer medication to her patient, and she mistakenly took the wrong medications from the drug cart. If the trainee nurse had not discovered the error, the nurse would have administered the wrong medication to the patient without her knowledge. The nurse had unintentionally taken a drug cap that belonged to a different patient. It is clear that it is very easy to mistake medication especially if the environment is cluttered. Sharing a working space with another nurse makes it easy for the nurses to confuse drugs. If the drug cups were the same color, it would have been difficult to discover the error.

Best practice for a cluttered environment

When working in a cluttered environment, the nurses should be careful not to mix up the medications for the different patients. It would be advisable that the nurses double check their medications. This way they will reduce the chances of mixing up medications. Using color coded drug cups could also assist in reducing the medication errors. Nurses would easily identify the cup colors, and this would ensure that they administer the correct medication. Color coded could still result in errors if the environment is cluttered as a nurse could put the wrong pills in the correct cup. Nurses should therefore, check correctly that they are using the correct drug as prescribed. Double checking the drugs is vital, and this would assist in reducing medication errors. Medication errors are a process issue as nurses are trained to always administer the correct dosage to patients. It is during the process of drug administration that an error could occur. A registered nurse could easily confuse the drugs to be administered because of a cluttered environment. The process of drug administration should be refined to ensure that even when working in a cluttered environment the nurse remembers to confirm the medications.

Nurses could be trained on always confirming their patient medications before administration. This way a nurse will develop a new process of always double checking medications. Training the nurses to be conscious when administering drugs would also assist in reducing the errors of medication. There should also be consequences for the nurse who administers the wrong medication. Currently nurses are not punished for administering the wrong medication, which might be a major cause for relaxation in administering medications. Nurses refuse to report any medication errors due to fear of the consequences like law suits. This fear makes it hard to determine the extent of medication errors.


Nurses are trained to be careful when administering drugs to patients, but once they reach their work environment the situation changes and they have to adapt. Nurses have to Eisenhauer, Hurley, & Dolan, 2007()

-task in order to manage their workload. Multi-tasking mostly results in errors of medication as the nurse is performing different tasks at the same time. Performing another task while administering a drug reduces the nurse's concentration, this could result in a medication error. Nurses try to prepare patient medication in advance in order to make it easy when making rounds. This is a noble way of handling the workload, but it has negative results as the nurse will most likely mix up the patient medications. Educating nurses on the best methods for managing their increasing workload would assist them in reducing medication errors. The nurses would still be multi-tasking, but they would now be armed with knowledge on how to pay attention to what they are doing.

Tissot et al. (2003)

states that the number of patients per nurse has a direct effect on the number of medication errors. A nurse who is handling more patients is more likely to make an error in drug administration. Training the nurses on how to handle more patients would increase their knowledge. Educating nurses on calculation of dosage would also reduce the medication errors. Some dosages are based on the patient's age, and weight. Koren, Barzilay, and Modan (1983)

indicate that 8% of calculations had errors. This indicates that training and education would assist in reducing the errors. The errors were not limited to inexperienced nurses, but also the experienced nurses. Training would also provide the nurses with information on how to handle a cluttered environment. The training would include practical's that would assist the nurses to simulate an actual cluttered environment. Using practicals, the nurses would be able to learn how to manage their medications and ensure they do not mix up the dosages.

Further research

The literature reviewed was mainly focused on the general causes of medication errors. There was no research that focused on a specific area in terms of medication errors. This has made the research to be generalized towards medication errors. The other area that the literature has focused on is the ethical implications of medication errors Luk, Ng, Ko, & Ung, 2008.

There is little literature regarding medication errors due to a cluttered environment. This is… [END OF PREVIEW]

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Cite This Capstone Project:

APA Format

Medication Errors Due to Cluttered.  (2013, November 15).  Retrieved July 15, 2019, from

MLA Format

"Medication Errors Due to Cluttered."  15 November 2013.  Web.  15 July 2019. <>.

Chicago Format

"Medication Errors Due to Cluttered."  November 15, 2013.  Accessed July 15, 2019.