How to Reduce Medication Errors

Medication errors are largely the result of human error, and it is primarily considered the responsibility of the nurse delegated to administer medication. Such was the case when an experienced hospital nurse administered potassium chloride to a patient after checking the vial three separate times to be sure it was the drug prescribed, which was Lasix (Green, 2004, p. 37). The patient died, and a subsequent investigation found that the vial was labeled correctly and that the nurse had no explanation for the error (Green, 2004, p. 37).

Although at first blush, the nurse appears to be negligent and fully responsible for the "look but fail to see" error, "an inquiry that is judgmental and narrowly focused on the nurse is likely to overlook system and procedure faults" (Green, 2004, p. 37). For example, the 1998 Patient Safety study found that potassium chloride had been confused with other drugs, Lasix included, on frequent occasions because of similar packaging (Green, 2004, p. 37). In addition, the drawer where the drugs were kept had no dividers to keep different drugs separate, so the potassium chloride could easily have fallen into the Lasix part of

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