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  1. Cohen, Hedy RN, BSN, MS

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A patient was diagnosed with a stroke in the ED. Because he couldn't speak, his wife gave the ED nurses an account of his current medications, which included methotrexate 7.5 mg weekly for severe rheumatoid arthritis. When writing admission orders, the medical resident mistakenly wrote methotrexate 7.5 mg to be given daily, not weekly. When the patient arrived in the intensive care unit, his nurse checked the medication administration record transcribed by the unit clerk against the physician orders for accuracy. She then sent the physician's order sheet to the pharmacy; the pharmacy profiled the medication as written and dispensed the medication.

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The patient remained in the hospital for 10 days and received methotrexate 7.5 mg every day. He developed severe bone marrow suppression and renal failure, and died. The error was uncovered only later, during a review of his medical records.


This type of tragedy is far from unique-in American hospitals, 7,000 patients die each year from medication errors and about 450,000 adverse drug events are linked to preventable medication errors.1


Medication errors originate across the spectrum of care: prescribing 39%, transcribing 17%, dispensing 11%, and administering 38%.2 Yet nurses, the practitioners most likely to administer drugs, carry the heaviest burden for capturing an error before it reaches the patient. And they must catch not only their own mistakes, but also those made by other practitioners up the line.


Being a knowledgeable and conscientious nurse isn't enough to eliminate errors. The nurses in the above example all followed the "five rights," yet a fatal error slipped by. We need to move from "silo thinking" to a patient-centered approach where all practitioners work together to improve patient safety.


As vice-president of the nonprofit Institute for Safe Medication Practices (ISMP), I'm dedicated to promoting strategies for reducing medication errors. I've designed the survey appearing on page 8 of this issue to investigate nurses' attitudes and experiences regarding medication administration and error reporting.


Please take a few minutes to respond to the survey. Your candid answers will help researchers identify issues in nursing practice that contribute to errors and formulate practical strategies to improve safety. I'll report on your responses and their implications for nursing practice in a future issue of Nursing.


No one should die from a preventable error. By participating in this survey, you can contribute to building safer medication-use systems that help protect all our patients from harm.


Hedy Cohen, RN, BSN, MS


Vice-President, Institute for Safe Medication Practices, Huntingdon Valley, Pa.




1. Aspden P, et al. (eds). Preventing Medication Errors. Institute of Medicine. National Academy Press, 2007. [Context Link]


2. Leape LL, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 274:35-43, 1995. [Context Link]