9 Nursing Medication Errors That KILL
Did you know that medication errors are the 3rd leading cause of death in the United States — right behind heart disease and cancer?
Med errors account for more than 250,000 US deaths every year. Most nursing medication errors don't actually kill our patients, but they do increase morbidity, hospital admissions, and length of stay, and decrease quality of life. Nurses administer almost all of the medications in the hospital, which puts us on the front lines of causing — or preventing — these errors. It takes a team of nurses, doctors, pharmacists, and patients to reduce them.
1. Nitro Paste
There's a reason Nitropaste only seems to be good for one thing — causing headaches! One reason it sometimes doesn't work well is medication errors in administration.
If you're anything like I was as a new grad, you may have been taught to squirt a thin line of nitropaste to the ½-inch or 1-inch mark. This leaves a good amount of paste left over in the packet. What some nurses fail to realize is that this is incorrect dosing.
You might say, "OK, but underdosing nitropaste isn't exactly killing my patient." But it can. Nitroglycerin is a super important medication in acute coronary syndrome (heart attacks). If the patient has a blocked coronary artery, nitro dilates those arteries, improves blood flow around the obstruction, and can save cardiac tissue and the patient's life. It also decreases preload and afterload in CHF patients — so the correct dose matters.
2. Ceftriaxone and Lactated Ringer's
IV medication drips are very common in the hospital. Patients often have IV fluids running as primary, plus secondary IV pushes or antibiotics. This isn't an issue with normal saline, as just about every drug is compatible with NSS. But sometimes Lactated Ringer's (LR) is ordered instead.
Ceftriaxone + Calcium = Bad
Don't give ceftriaxone (Rocephin) with IV LR. LR contains calcium, and ceftriaxone + calcium can form precipitates that damage the kidneys, lungs, or gallbladder. This is easily missed in the ED, where many nurses mix their own antibiotics and hang them secondary to whatever fluid is running.
Also check out: Intravenous Fluids: Types of IV Fluids
3. Paralytic Before Sedation
Rapid Sequence Intubation (RSI) describes the steps taken to intubate a patient who is awake (for now). Since we're about to put a tube down their trachea and breathe for them, this requires sedation. To stop the body from fighting the intubation, it also requires a paralytic. During RSI there is a specific sequence that must be followed.
Always Sedate Before Paralyzing
If you paralyze someone before knocking them out, they'll be terrified — unable to breathe or move, aware of the whole ordeal. This won't necessarily kill the patient, but it makes the process traumatic, and the patient can remember the whole thing when they wake up.
4. IV Insulin
It doesn't take long to realize how common diabetes is in hospitalized patients. Diabetics come in for DKA, Hyperosmolar Hyperglycemic State (HHS), or may need IV insulin for hyperkalemia (to push K+ back into the cells). Insulin is usually given SubQ, so some nurses aren't used to giving it IV — and those SubQ insulin needles don't hook up to a needleless IV system.
The easiest way is to draw the insulin (usually 5–10 units) into your normal subcutaneous syringe. Verify this dose with another nurse — most facilities require it.
Take a sterile NS flush, squirt half out, pull back on the syringe to make room, and squirt the insulin in. You've now diluted the insulin with ~5 mL of saline.
Don't set the syringe down — label it per facility protocol and give it like any other IV push medication.
The 10x Overdose Risk
Many nurses draw insulin up in a regular 3 mL syringe and patients get up to 10× the ordered dose. This leads to hypoglycemia and the need for close monitoring. Worst case, this error can lead to death — there have been accidental deaths from insulin overdoses.
Clinical Tip: Check the Syringe AND the Vial
When verifying ANY high-risk medication, look at both the syringe and the vial. I once had a nurse ask me to verify a 1 mL (5,000 u) SubQ heparin dose — turns out she'd actually drawn up 1 mL of insulin lispro! That's 100 units, much higher than most can tolerate. The error was avoided by verifying both the amount and the vial.
5. Look-Alike / Sound-Alike
You may have heard about this: a nurse in Tennessee accidentally killed a patient when she administered VECURONIUM instead of VERSED. It was ordered to calm the patient down at MRI; the nurse grabbed it from the Accu-Dose, overrode the medication, and administered the paralytic. There are many nursing errors in this scenario.
Overriding the Accu-Dose System
This is usually a major no-no on the floors, but in the ED it's common for pain meds, Zofran, Ativan, etc. The ED doesn't always have the luxury of waiting for pharmacy verification. If you absolutely have to override, be hypervigilant about which medication you're pulling and reconstituting. If you're unsure of a medication — ask for help. You shouldn't be giving a medication you don't know about anyway. Always know the intended use, appropriate dosing, and side effects to monitor.
Appropriate Monitoring
Monitoring is an essential aspect of nursing management — you're at the bedside and will be the first to notice a change in status. It's especially important after any IV medication, but particularly high-risk meds like IV narcotics or sedatives.
6. IV Haldol
Speaking of monitoring, it's also necessary to have a cardiac monitor during and after administration of certain medications, because some can cause arrhythmias and you want to identify them immediately.
Haldol can be given IV for agitation, dementia, and sometimes nausea. Unfortunately, it is high-risk for cardiac arrhythmias by increasing the QT interval, predisposing the patient to PVCs, VTACH, Torsades, and even VFIB. It's also technically to be avoided in dementia-related agitation due to an increased risk of sudden death. While options are limited and Haldol may still be needed, appropriate measures including cardiac monitoring should be used, at least when given IV.
Also check out: VTACH + VFIB: A Nurse's Guide to Ventricular Arrhythmias · How to Read an EKG Rhythm Strip
7. IV Push, Not IV Slam
Giving IV push medications is very common: Zofran, IV narcotics, Toradol, Lasix, and many others. Nurses are busy, which tempts us to quickly give a medication and move on. But medications given too fast can cause unpleasant — even disastrous — side effects.
Also check out: Adverse Drug Reactions Nurses Need to Know
8. Proper IM Location
When I was a nurse, I was taught to inject most IM medications > 1 mL "in the butt" — but where in the butt wasn't really specified. Many nurses just shoot for the middle of the buttock (dorsogluteal), which can actually cause injury.
Avoid the Dorsogluteal Site
Injecting in the dorsogluteal region can lead to skin and tissue trauma, muscle fibrosis and contracture, hematoma, nerve palsy, paralysis, and infection. Instead, these medications should be given in the ventrogluteal site.
The deltoid is an easy location for injections of 1–2 mL in most adults, though even 1 mL can be painful and it's not recommended for repeat injections (small surface area). An important fact: the vastus lateralis (side of the thigh) offers the quickest absorption. So for a patient in severe anaphylaxis, your best bet is to inject epinephrine in the thigh rather than the arm.
9. Broad Before Narrow
Antibiotics are given all the time in the hospital. Septic patients may need immediate treatment with multiple IV antibiotics. Some antibiotics are broad-spectrum (killing many types of bacteria) and others are narrow (killing fewer). You always want to hang the broad-spectrum antibiotic first, ensuring the agent most likely to help is given first.
Vancomycin Is NOT Broad-Spectrum
One common mistake: nurses think Vancomycin is broad because it's a "heavy hitter," but Vancomycin is narrow — it mainly covers gram-positive organisms. Unless the bug is MRSA or another gram-positive infection, it's less likely to help, and it takes ~1.5–2 hours to infuse anyway.
Clinical Pearls
Related Guides
References
- Ceftriaxone and Lactated Ringer's incompatibility.
- Haloperidol: Drug information (UpToDate).
- Dexamethasone (systemic): Drug information (UpToDate).
- Metoclopramide (Reglan): Drug information (UpToDate).
- Medical errors: third leading cause of death in America (CNBC).
- NitroBid 1 gm = 1 inch (Nursing).
- Ventrogluteal vs Dorsogluteal IM Injection.
Hello, I really enjoyed reading this. Can you send me the evidenced based references for this? I would like to read more please. Thank you so much for posting this info.
Thank you for this. I think we often assume people know things but that is not always the case. I’ve been told to “just do it” before & I promised myself never again! I have experienced some nurses withholding info to make themselves look better! We need to help each other, support one another so we all can be successful taking good care of the patients. I have been a nurse for a long time & sometimes feel like asking a question is so embarrassing. We are all human & no one nurse can possibly know everything! Thank you again… Read more »
I absolutely agree! It’s always better to question an order and “feel dumb” than to give it without being sure its safe!
Everything I can find on nitro-bid 2% paste dosing says 1” – I cannot find any information that says it should be 1 square inch. Where are you getting the information that states the dose is 1 square inch?
You’re right – nowhere is it specified that says “1 square inch”. And it might be because there are varying thicknesses of the paste depending on what sized tube you are using vs individual foilpacs. I have removed this wording to avoid confusion. The main point is that the individual 1gm foilpac is equivalent to 1 inch dosing ordered by the physician. You can see that information on the individual foilpacs and also at https://www.drugs.com/dosage/nitro-bid.html – I hope that helps, sorry for any confusion!
Love your page. I am an new ER RN & you videos and readings are so helpful. Keep it up!
That’s great, thanks for reading!
In discussing diluting medications you mentioned adding the prescribed medication directly to your saline flush. This is a common error.. This is not good practice, and actually increases risk of both med errors and contamination. Best practice is to draw up your desired volume of NSS from a vial, then to draw the medication up into the same syringe. It is not good practice to transfer medications to different syringes. And of course, don’t forget to la el the syringe even if administering immediately.
Otherwise, informative post!
Thanks for your input Bridgette! While I am sure that is the correct textbook answer, I am not sure if it is practical. I don’t know of many units that have a bunch of spare NS vials around – but I know a bunch with flushes to spare! It also seems tedious when a quicker and more practical approach to using a flush is an alternative. I’d also argue that drawing up insulin in a 3-5ml syringe is much less accurate than first drawing it up in an insulin syringe or TB syringe, and then transferring it safely to a… Read more »
I admit that I myself have used a prefilled NS flush to dilute medications. That is how I was taught. At the time I was unaware that this was not best practice or a safety hazard. It is true that it may seem quicker or easier to use a NS flush, but the fact is that this is a short cut and does increase errors and liability. NS vials should be available in all the medication prep areas or within the MCKesson Accudose. If they are not, cases of them can easily be requested or ordered from Pharmacy. Identifying this… Read more »
https://www.ncivps.org/faqs
Hi bridgette
I appreciate all the info you gave! I’m just wondering what exactly are the risks of using a sterile saline flush vs drawing NS from a vial? I don’t understand where infection risks come from?
I have been a nurse for 20yrs mostly in a FSED. This is some of the best and most accurate information I have seen. Especially for our newbies! Keep up the good work!
I LOVE that! Thank you 🙂
You info is absolutely ? correct and thank you for your transparency. We need more nurses that are willing to share best practices with other nurses so I really thank you ?. Do you have a channel so I can follow you. Im currently a LPN and in my first semester RN program and already I’ve seen improper ways to administer meds mainly from those nurses who forgot what its like to be a nursing student.
Katrina, Thanks so much for your feedback! I have a YouTube channel and an email list where you can stay updated on everything with Health And Willness! Do you want me to add you? http://youtube.com/willkellynp
Bridgette is correct. Even if you need to use the saline from a flush to dilute something because there are no vials, it should be drawn up into a regular 3 mL (or whatever the most appropriate size is) syringe. It is a huge no no to add meds to a normal saline syringe because they are pre-labeled as 0.9% normal saline flushes. The Joint Commission would have a field day with that.
Absolutely
Without looking up the author of this post, I knew he or she was an ER provider!!!!
You know it!!
This is really helpful for a new nurse like me! Thank you so much!
You’re welcome!
Hey, great article! I do want to point out a grammar error that I think if fixed would make it even more credible: “ you may have been taught to squirt put a thin line of nitro-paste.” The error is “squirt put” – you need to remove one of the words, each word makes sense but they don’t belong together. Also, this I have never heard of with the amount you squirt. I’ve had a pharmacist on my unit prepare it for me and they did not do this. Do you have the reference for this?
Thanks!