Medication Errors

Table of Contents

A medication error is defined by the Food and Drug Administration as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. (National Coordinating Council for Medication Error Reporting and Prevention, 2019).

 A few samples of medication errors that can occur in schools include: 

  • failure to administer medication to the student
  • failure to administer medication within the designated time
  • failure to administer the correct dosage of medication
  • failure to administer medication by proper route
  • failure to administer medication according to generally accepted standards of practice
  • administering the wrong medication to the wrong student
  • administering medication without parent authorization, or
  • administering a prescription medication to a student who does not have a prescription.

Medication errors can occur as human care may be fallible. School personnel should notify the school nurse, parent, healthcare provider and administration if a medication error occurs right away to create a safe environment. Staying connected, transparent and communicating with parents is an essential reparative step in addressing improving the process of medication administration. It is best-practice for school nurses and school personnel to have a dialogue with parents that includes: 

  • Recognition of the adverse outcome
  • Regret by offering empathy
  • Responsibility where needed and explain how the event happened
  • Remedy by explaining next steps to correct and prevent reoccurrence
  • Remain engaged by communicating with parents

When a medication administration error occurs by a paraprofessional:

  1. Keep the student in the health room (or room where medication was administered)
  2. If the student has already returned to class, have someone accompany the student back to the room where medication was administered
  3. Observe the student’s status and document what you observe
  4. Remain calm and do not alarm the student
  5. Identify the incorrect dose or type of medication taken by the student
  6. Notify the school nurse, parents and administrator immediately
  7. Notify the prescribing provider of the medication
  8. Notify the parents and prescribing provider of the other child’s medication (if applicable to the error)
  9. If contacting the Poison Control Center for instructions:
    1. give the name and dose of the medication taken in error
    2. give the student’s age and approximate weight, if possible
    3. give the name and dose of any other medication the student receives, if possible
    4. Follow instructions from the Poison Control Center, if possible.
      1. If unable to follow their instructions, explain the problem to the Poison Control Center to determine if the student should be transported for emergency care
  10. Complete a Medication Administration Incident Report form.
    1. Carefully record all circumstances, the student’s status, communications and actions taken, including instructions from the Poison Control Center or the student’s health care provider..
    2. All reports are to be filed and kept according to school or program policy
  11. Give or send the completed Medication Administration Incident Report form securely to the delegating school nurse within 24 hours of the incident.
  12. Follow any additional school or program procedure
  13. Debrief with the school nurse.

School Nurse Responsibilities:

  • Upon notification of medication error, contact the parents of the student and health care provider, if not already completed
  • Review Medication Administration Incident Report form immediately with the delegatee who was involved in medication error
  • Provide additional education to employee(s) who was involved in medication error
  • Ensure competency of employee who was involved in medication error on safe medication administration
  • If necessary, revoke delegation and identify someone else to assume responsibility of medication administration
  • In conjunction with school administration, review data on Medication Administration error report forms at least quarterly to understand:
    • the factors that contribute to errors and
    • identify if the errors are related to systems and/or process issues
    • Identify process changes that may need to occur to improve medication administration procedures, for example:
      • Reducing distractions when/where the medications are being given
      • Having photos of the student attached to the medication administration form to assist with proper identification
      • Providing more frequent medication administration education refreshers