InfoLAW: Medication Errors

Medication errors are a relatively common occurrence in nursing practice that can cause life-threatening complications for patients. According to a Health Report completed by Statistics Canada, “almost one-fifth (19%) of hospital-employed Registered Nurses acknowledged that over the previous year, medication errors involving patients who were in their care had occurred “occasionally” or “frequently”“.¹ In fact, medication errors were only second to surgical errors as the most common type of mistake in healthcare.² Although nurses are trained to administer medication, errors can occur regardless of their years of expertise or education.³ Errors can range from simple miscalculations involving one healthcare professional, to complex errors with multiple contributing factors. These incidents can result in serious consequences for patients, and legal repercussions for the nurses involved. However, there are many ways to mitigate medication errors, including abiding by applicable professional standards, being aware of the consequences, and employing risk-management techniques when administering medication. 

What professional standards are considered when administering medication?

A nurse’s scope of practice and responsibility concerning medication administration are typically determined by the professional nursing standards established by their provincial or territorial regulatory body. A nurse should confirm that the activity is within their scope of practice and assigned tasks prior to completing the intervention. It is also important to consult these practice standards, where available, should any medication administration questions or concerns arise.⁴ 

Health institutions generally have policies and procedures regarding medication administration, its documentation and the reporting of a medication error or adverse events. For example, one nursing regulator states that “employers are responsible for providing the organizational supports and systems necessary for safe medication administration by nurses, including medication reconciliation and supporting voluntary reporting of medication incidents and near misses”.⁵  

Once medication is prescribed, a common aid to proper administration is the list of the “rights of medication administration” which generally include the following principles: the right drug (medication), the right dose, the right patient, the right route, the right time and the right frequency. With the evolution of medical research, the rights have become more exhaustive, and now may include principles such as the right documentation, the right reason, the right patient education, the right assessment and evaluation, and the patient’s right to refuse.⁶

What is the procedure to generally follow in the event of a medication error? 

First, it is important to report the error as soon as possible to ensure the proper response is taken to treat the affected patient. A recent case reminds us that “the person who made the error must be honest and report it so that the patient can be treated”⁷ as soon as possible. In this case, the nurse was terminated as she breached her fundamental professional obligations and endangered several of her patients by administering incorrect medications and lying about these actions.⁸ Each employer may have different established reporting protocols, and nurses should consult these protocols once the patient has been cared for appropriately.  

What are the potential consequences if an error occurs?

When an error has been identified, the first priority is to ensure proper treatment of the patient, report the situation to the responsible care provider and employer, and complete any relevant incident report. The professional consequences after a medication error will depend on a number of factors, including previous work performance, degree of harm to the patient, and response to the error. Any or all of the following could occur: 

• • Patient safety or quality assurance review: 
    Nurses are expected to be knowledgeable about the actions, side effects, drug interactions, and contraindications of medications. The employer may conduct an internal review to determine how and why the error occurred in order to improve the environment or system in which nurses administer medications.⁹ 
  • Employee discipline: 
    An employer may require that a nurse improves their competencies. In certain circumstances, a nurse may be reprimanded, suspended, or dismissed. 
  • Professional discipline: 
    A complaint to the nurse’s regulatory body may trigger an investigation. If the licensing body requires remediation of practice, the nurse may be ordered to engage in a course of study. The nurse’s licence may also be suspended or revoked. Although the discipline will usually be proportionate to the misconduct, there is no set formula to predict the outcome. Here are a few examples of such situations: 
    • • A nurse received a 6-month suspension and a reprimand after several allegations regarding the improper dispensation and documentation of Fentanyl and Methadone, and failing to report medication errors.¹⁰
      • In a recent case, the nurse in question had her licensed revoked after numerous allegations of medication errors. These included failing to document errors, striking through another nurse’s entry on a medication administration record, and leaving a patient’s health-care record in a cell they shared with another inmate.¹¹

• • Civil action: 
    A patient or a patient’s family may commence a civil action (sue) the nurse and/or the nurse’s employer for negligence if a medication error occurs. A civil action is possible even if a nurse is not found criminally negligent, as the burden of proof is different.  
    • In one of Canada’s landmark negligence cases related to medication errors, a fatal error occurred when a physician asked a nurse to obtain novocaine to inject into a patient’s thumb and was provided with adrenaline instead. The nurse had asked another nurse in a different area for the drug and was given a vial, which she then took to the physician who injected the medication. Neither the nurses nor the physician had looked at the label on the bottle. As a result, both nurses were found negligent. The Court found that the physician was not negligent, because he had been justified in relying on the competency of the nurses to check the label.¹²

• • An important consideration: 
    • A nurse can be disciplined or reprimanded even if the patient has suffered no undue harm. In fact, there have been many instances of this in Canada. For example, in a case where a nurse administered the wrong type of blood, the court ruled that the defendant could not accept any credit for the fact that the patient had not suffered any harm, as the “nature of [their] offense is the same as it would have been had the wrong blood proved fatal.”¹³

What considerations can be taken to assist in decreasing the likelihood of a medication error?

Nurses may wish to consider the following: 

• • Pay close attention to all aspects of medication administration (see above for the “rights”); 
  • Know and follow their institution’s procedures relating to the administration of medications; 
  • Practise computational skills or use a calculator, and where policy dictates, have another health-care professional independently double-check their calculations;¹⁴
  • Understand the drugs they are administering and the conditions or interactions that may occur based on the patient’s health history; 
  • Remember that nurses should immediately report all adverse drug reactions to their employer. In fact, health facilities are now required to report serious drug reactions and medical device incidents to Health Canada.¹⁵
  • Keep up-to-date with current practices, equipment and techniques; 
  • Do not administer medications prepared by someone else;  
  • In fact, many medication guidelines indicate nurses should only administer medication prepared by themselves.¹⁶ Please keep in mind that this is a general rule that does not apply in emergencies. Another possible exception is medication prepared by a pharmacy.¹⁷

• • Clarify orders if they are incomplete, illegible, or contain unapproved abbreviations; 
  • Question orders that appear inappropriate (such as an unusually high dose); 
  • Chart medications according to institutional guidelines and only when given by themselves, except when a nurse is designated as a recorder in an emergency; 
  • Exercise prudence and critical thinking when transcribing medication orders; 
  • Verify the patient’s informed consent. 

Another strategy to decrease the possibility of a medication error is known as medication reconciliation. This is a formal process of obtaining an accurate list of a patient’s current medications and using that list to write admission, transfer and discharge orders to reduce the incidence of discrepancies in medication orders.¹⁸ This will help ensure that medications that are added, changed or discontinued are being carefully evaluated, resulting in the most appropriate prescribing decision for the patient.¹⁹ 

Key takeaways 

Medication errors occur, but understanding the principles related to medication administration can assist in mitigating potential risks or consequences. It is best to act prudently and follow standards vigilantly when administering medication. 

If an error occurs, the appropriate steps should be taken to address the patient’s condition. It is important to document the incident or near-miss and report it immediately to the patient’s primary healthcare provider and your employer. In addition, complete any additional documentation required by your employer.  

Do you have more specific questions? CNPS beneficiaries can contact 1-800-267-3390 to speak with CNPS legal counsel. All calls are confidential. .

1. Kathryn Wilkins and Margot Shields, Correlates of medication error in hospitals, revised in 2015. 
2. Ibid.
3. Ibid.
4. Please consult the applicable resource for your provincial or territorial standards.
5. British Columbia College of Nursing Nurses and Midwives, Medication Administration, 2021.
6. Saskatchewan Registered Nurses Association, Medication Management for RNs: A Patient Centered Decision-making Framework, September 2015.  
7. Baptiste v Deputy Head (Correctional Service of Canada), [2011] PSLRB No 130
8. Ibid.
9. Nurses and other healthcare professionals may confidentially report medication incidents including near-misses, by healthcare facilities, individual practitioners, consumers, patients and pharmacies, to the Institute for Safe Medication Practices Canada. Healthcare facilities report medication incidents to the National System for Incident Reporting through the Canadian Institute for Health Information. Both of these programs are a part of the Canadian Medication Incident Reporting and Prevention System. Nurses should verify with their health institution’s policy before doing so.
10. College of Nurses of Ontario v Taylor, [2013] CanLII 93851 (ON CNO).
11. College of Nurses of Ontario v Freyer, [2018] CanLII 90852 (ON CNO).
12. Bugden v. Harbour View Hospital et al. [1947] 2 D.L.R. 338 (N.S.S.C.).
13. United Nurses of Alberta v Alberta Health Services (Brown Grievance), [2018] AGAA No 10
14. Many facilities require independent double-checks for the preparation and/or administration of high-alert medications, such as those identified by the Institute for Safe Medication Practices. For example, the High-Alert Medications in Acute Care Settings list is available at: https://www.ismp.org/recommendations/high-alert-medications-acute-list.
15. Health Canada, Canada Vigilance Adverse Reaction Reporting Form. 
16. College & Association of Registered Nurses of Alberta, Medication Management Standards, March 2021, current standard reads: “1.19 only administer medications prepared by themselves or a pharmacist (or pharmacy technician), except in urgent or emergent circumstances when the medication may be prepared by another health care professional as outlined in employer requirements”;
17. Ibid. 
18. Canadian Patient Safety Institute, Medication Safety
19.  Canadian Patient Safety Institute, Hospital Harm Improvement Resource: Medication Incidents, April 2016. 

November 2021

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.