Proper Staffing to Prevent Medication Errors

Amy Connolly & Andrea Hintz

Case Exemplar

"A pharmacy technician stocked an automated dispensing cabinet with heparin 10,000 units/ml vials in a drawer reserved for heparin 10 units/ml. The nurses retrieving the vials [were understaffed] and did not notice the discrepancy in strength and used the 10,000 units/ml heparin for umbilical line flushes of six premature infants. Three of the babies died of heparin overdose."

Literature Review

Preventing Medication Errors

This article discusses the cost of medication errors, both monetarily and in regard to patient health.   It also recommends a change in medication labeling and packaging, as well as the use of IT to prevent medication errors.

Establishing Criteria for 1:1 Staffing Ratios

This article succinctly maps out the criteria necessary for establishing 1:1 nursing ratios in an acute care environment.

The Effect of Nurse Staffing Patterns on Medical Errors and Nurse Burnout

This journal article discusses the ways in which staffing ratios influence medication errors and increase the rate at which nurses experience burnout.

SWOT Analysis

Significance of Quality Issue

Lives are changed in an instant...due to a preventable mistake.

QSEN Competencies

Teamwork and Collaboration

Definition: "Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care."

Relation to study: "Function competently within own scope of practice as a member of the health care team." Understanding one's own ability to function independently and provide competent care; but also having the humility to ask for help if one does not know how to proceed can help prevent potentially fatal medication errors.


Definition: "Minimize risk of harm to patients and providers through both system effectiveness and individual performance."

Relation to the study: "Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as root-cause analysis and failure mode effects analysis)." Being able to admit to making a mistake or a near mistake is critical to ensure the safety of patients.  Even if something was a "near-miss" it should still be documented because if one person made that mistake, chances are others could do the same.

(Cronenwett, et al., 2007)



  • For every medication error that occurs it is estimated that the total cost of a hospital stay will increase by more than $8000 (Institute of Medicine, 2006).
  • This is approximately $3.5 billion annually!


  • Estimated that 380,000-450,000 adverse drug events occur each year in hospitals across the United States (Institute of Medicine, 2006)

How does this affect our nursing practice?

  • As nurses of the future, this could cause a lack of trust for other nurses in the field.  Mistakes happen, we are only human, but the multitude of mistakes occurring in one year are major red flags. Something must be done.  Poor staffing can cause less time spent with patients, rushing, and burnout.  Don't let this happen to you!

Nursing Implications

Practice: nurses should work in a space with no interruptions and adequate lighting.  The introduction of BCMA helps to reduce errors but this option is NOT a fail safe, use at least the 5 Rights of Medication Administration, "double check" by another nurse

Education: continuing education should be taken as a high priority, especially when new medications are introduced to a facility; this includes that facilities are being updated regarding medication errors that are occurring both inside and outside their facilities; updates to P&P should be readily available to staff; nurses should also attend pharmacy grand rounds

Research: the introduction of computerized order entry may reduce errors up to 50%, continue to learn as much about medications and adverse reactions to help prevent errors in the future or near-miss events

(Anderson & Townsend, 2010)

Organizational Plan

In order to improve patient outcomes, an organization should have specific procedures when it comes to determining the criteria for staffing ratios.  This could be done using an algorithm to determine how complex a patient may be.  It could also be based on the medications the patient is taking or if the patient is on a ventilator, for example.

Incident reports should be filled out for near-misses or if a never event occurs so that the hospital can track the amount of errors made.  This could also help the facility and supervisors understand why the mistake happened in the first place and allow for possible solutions to the problems.

SMART Criteria

There will be no medication errors following the implementation of criteria for nursing staff ratios in ICUs by October 31st, 2015.


  • Anderson, P., & Townsend, T. (2010, March). Medication errors: Don't let them happen to you - American Nurse Today. Retrieved from
  • CBS News. (2008, March 14). Quaids speak out [Video file]. Retrieved from
  • Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 121-131. doi:10.1016/j.outlook.2007.02.006
  • Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. Aorn, 87(6). doi:10.1016/j.aorn.2008.01.022
  • Hartigan, R. C. (2000). Establishing criteria for 1:1 staffing ratios. Critical Care Nurse, 20(2). Retrieved from
  • Institute of Medicine. (2006). Preventing medication errors. Washington, DC; National Academy of Sciences. Retrieved from
  • Magill-Lewis, J. (2007, April 2). Caution: Heparin errors can have fatal results. Retrieved from
  • Medication error song [Video file]. (2013, July 1). Retrieved from