Medication administration errors by nurses: adherence to guidelines

J Clin Nurs. 2013 Feb;22(3-4):590-8. doi: 10.1111/j.1365-2702.2012.04344.x. Epub 2012 Dec 10.


Aims & objectives: Medication administration errors represent one of the major concerns in patient safety. We aimed to study the rate using more robust methods for the correct results.

Backgrounds: Very few studies have been carried out on medication administration error frequency. Previous studies of medication error frequency have used mainly surveys of clinical nurses, which may result in substantial undercounts.

Design & methods: We developed a checklist using basic medication guidelines including the Five Rights, infection recommendations and medication recording rules. After validity and reliability were confirmed, we performed direct observation using a checklist to evaluate the medication activities of clinical nurses.

Results: We observed total 293 cases of medication activities, collected data and calculated adherence ratios per item. Only 45·6% of nurses verified the amount of medication indicated on the vial at least once for at least one-second. In addition, only 6·5% read the name of the patient from the wristband. Administering the medication at the correct time guideline was observed 41·0% of the time. The guideline regarding hand washing before external and oral medications was followed only 4·5% of the time, although this figure was much higher for intravenous medications at 96·6%. Overall, among 31 categories regarding drug administration, 17·2 (± 3·6) items per person were followed, whereas 5·7 (± 1·2) items per person were violated.

Conclusion: Thus, the results overall showed low rates of adherence to guidelines, suggesting that many medication administration guidelines are not strictly followed. We found key instances in which nurses did not follow the guidelines, including many from the Five Rights. About one in four elements were violated overall.

Relevance to clinical practice: The results of this study could be adopted to make guidelines of medication administration more practical for the clinical nurses to adhere.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Guideline Adherence*
  • Humans
  • Medication Errors*
  • Nursing Staff*
  • Patient Safety
  • Republic of Korea