Understanding Medication Errors: Discussion of a Case Involving a Urinary Catheter Implicated in a Wrong Route Error

Rodney W. Hicks, PhD, RN, FNP-BC, FAANP; Shawn Coniff Becker, MS, RN; Dorothy Greene Jackson, PhD, MSN, RN, NP-C


Urol Nurs. 2008;28(6):454-459. 

In This Article

Abstract and Introduction

Medication errors represent a failure in the medication use process leading to an increase in morbidity and mortality. In an effort to standardize reporting, evaluating, and trending of medication errors, the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) developed and maintains a medication error taxonomy. A case study involving a medication intended for administration via rectal tube and inadvertently given through a Foley catheter is discussed using the NCC MERP medication error taxonomy and critiqued using recent national findings. Awareness of national trends for patient safety, including emerging changes leading to best practices, updates to National Patient Safety Goals, and changes in national policy, can reduce the risk of error involvement.

In 1999, the first Institute of Medicine (IOM) report on the quality of U.S. health care, To Err is Human: Building a Safer Health System, catapulted patient safety to national attention. The IOM asserted that the system, in its present form, could annually expect as many as 98,000 individuals to become the fatal victims of medical errors, a number that exceeds the combined total deaths from motor vehicle accidents, HIV/AIDS, and breast cancer (Kohn, Corrigan, & Donaldson, 2000). Iatrogenic injuries became the 8th leading cause of death in America, and as many as 7,000 of deaths were from medication errors (Kohn et al., 2000). The 1999 IOM report highlighted that "people working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be safer" (p. 49). Because of the report, health care providers, payers, and policy makers became aware of this issue, the role of human error, and systems-related weaknesses within the world's most expensive health care system.

Nurses involved in urologic care must have a basic understanding of how to analyze and report medication errors. This requires a brief overview of the use of error taxonomy. Under standing components of this taxonomy will help nurses by providing a standard means to identify, record, interpret, track, and understand such events. The case study presented in this article is based on an actual error from a national medication error reporting program. Additionally, findings from a recent national medication error report will further advance knowledge about the breadth of this important topic.


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