Cases & Commentaries

Cups of Error

Commentary By Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN

The Case

An 87-year-old man was 5 days postoperative from
a decompressive laminectomy. Although he suffered from dementia, he
remained alert and oriented with only mild short-term memory loss.
During his stay at a rehabilitation unit, a nursing student
administered a “cup” of medications that included
clopidogrel (Plavix), carbidopa-levodopa (Sinemet), prednisone,
rivastigmine tartrate (Exelon), and risperidone (Risperdal).
Unfortunately, this cup of medications belonged to another patient
on the unit. As a result, the patient became drowsy with mild
nausea and hypotension, but the symptoms resolved within 24 hours
without further event. After learning about the error, the family
requested no further care from any nursing students.

On this particular unit, nursing students receive
supervision from a senior nursing instructor. The unit's policy
required that only the instructors access Pyxis (an automated drug
dispensing system) when administering medications. In this case,
the instructor attempted to save time by having the eight nursing
students prepare their medications from Pyxis at the same time;
after preparation, the instructor reviewed each student's
understanding of the medication(s) and preparation accuracy. After
this process was completed, the students left each of their
patients' medication(s) in a “cup” on the counter in
the medication room. When the time came to administer the
medication(s), the student in this case picked up the wrong cup of
medications for her patient.

The error was discovered when a different student
expecting to give the above medications reviewed the ones in her
cup and discovered the wrong medications—also a near miss for
her patient.

The Commentary

Individual vigilance in medication administration
is a critical, but fallible, mechanism to ensure safety and prevent
errors. The student who discovered the error and prevented a second
one demonstrated proper vigilance in rechecking the medications
before administration. The student involved in the actual error did
not. However, rather than applauding one student and reprimanding
the other (one can only imagine how devastated that student already
was after the error; it is hard to believe that a further reprimand
would make a material difference in her future conduct), this case
should raise the question of why any of the students failed to
recheck their medications and, further, why the instructor created
this unsafe situation.

Established guidelines consistently recommend
that medications be prepared for one patient at a time and
administered immediately.(1-4)
Furthermore, these guidelines state that drug labels be read three
times: when reaching for or preparing the medication, immediately
prior to administering the medication, and when discarding the
container or replacing it in storage. To follow these guidelines
carefully, the medication administration record (MAR) should be
taken by the nurse to the bedside, and medications should remain in
the unit-dose–labeled containers until administration. There,
the nurse can confirm the patient's identity (ensuring that it
matches the name on the medication label) and the specific
medication name, dose, formulation, and scheduled time against the
MAR just prior to administration. Finally, recommendations suggest
that the nurse should vocalize both the name and the indication of
each medication to the patient at the time of administration. This
practice would provide an opportunity for informed and cognitively
intact patients to recognize a discrepancy and bring it to the
nurse's attention. Why were these standards not followed in the
case presented? Drawing on our research and experience in teaching
and in practice, we present a few explanations.

In this case, battling the time constraints of
daily nursing work, the instructor substituted an efficient
approach for a safe one (in which she supervised the medication
preparation for all of her students at one time). This instructor
likely believed that her students understood both the need for
vigilance and their responsibility to recheck the medications at
the time of administration. Additional problems might have arisen
when all of the patients' medications were sitting open and
unobserved. The instructor's decision to allow this unsafe
situation is problematic from several perspectives. Most obviously,
it led to the medication error. Second, the situation role modeled
that it is acceptable to ignore recommended safe
practices—working around accepted protocols in the pursuit of
efficiency—to newcomers to the profession.

In addition to usual daily time constraints, the
instructor had been placed in a particularly difficult position.
Ideally, the instructor would be free to observe each student as
they prepared the medications immediately prior to administration.
With eight students, such individual observation would likely come
at the expense of supervising other crucial and potentially harmful
aspects of patient care. The traditional organization of nursing
clinical instruction dictates close one-on-one supervision of
beginning students. The reasons for this are understandable, but
ways to facilitate efficiency and safety in that context are
needed. Lower student-to-faculty ratios are expensive, and the
costs of nursing education are known to be higher than other
undergraduate training programs. Under current funding constraints,
nursing schools have difficulty maintaining the lower ratios.
Regulations of nursing education in most states require a lower
ratio for students in their initial clinical experiences. To
control the costs of clinical education and meet the requirements,
schools arrange for direct supervision of students in a preceptor
format, using the staff nurses in the hospital. As the workload of
staff nurses has increased in recent years, however, they are
reluctant to accept the responsibility for supervising nursing
students in addition to their other responsibilities. As the
shortage in both nursing faculty and hospital nursing staff
intensifies, this problem may become intractable.

Excluding students from directly accessing
automated medication-dispensing devices, such as Pyxis, is common
in training settings. To promote safety and efficiency, the staff
nurse or instructor may create a workaround for
systems designed to ensure safety, thereby creating new potential
safety issues. The situation exposes a fundamental tension in
training: the decision to not allow students to access automated
medication-dispensing devices (possibly made in the name of safety,
although it sometimes has more pedestrian roots, such as the
logistical difficulties in obtaining Pyxis codes for students)
leads to students completing nursing school without the experience
of individually selecting medications from these devices. Whether
the reason for the exclusion is safety or convenience, we suggest
that now is the time to create a shared culture of safety between
academic institutions and clinical training sites that balances the
problems of allowing students to access the dispensing devices with
the benefit of doing so. Because automatic dispensing devices
constitute a unique risk in medication administration (as evidenced
by the 9,000 errors reported in the 2003 USP annual report
nursing schools and clinical training sites need to design training
systems that allow students to develop essential competencies.
Moreover, bypassing this important component of medication
administration is counterproductive, because health care
institutions will have to provide training and supervision to new
graduates upon their employment.

As seen in this case, the inadvertent mix-up of
unlabeled medication cups represents an understandable and almost
predictable event—a veritable accident waiting to happen.
Prevention of human errors involves creating systems that place
barriers in the way of errors. One of the most important elements
of a safe system is a culture that values checking and double
checking of important processes, notwithstanding the inefficiency
of those steps. Health care providers in positions of authority
(instructors, managers, supervisors, attending physicians)
ultimately establish the culture in which care is provided. When
providers in these positions do not carefully and visibly follow
standards, one cannot expect staff members to perform differently.
Students, in particular, are unlikely to object or correct their
instructors and other people in positions of authority, a point
emphasized in previous Agency for Healthcare Research and Quality
(AHRQ) WebM&M discussions.(6,7)
Professors often speak and act with such high levels of confidence
that students conclude any suspicions they might have about the
accuracy of statements and actions must be wrong. Creating a
culture in which trainees and junior providers remain vigilant to
errors and feel comfortable raising any concerns is exactly what
teachers, supervisors, and others in authority must do.

If the instructor in this case had established a
culture in which students felt comfortable and were expected to
speak out when they observed an unsafe practice, this error may
have instead been a near miss. After speaking out, the student
could have been rewarded for making a “good catch,”
instead of having to complete an incident report and go home to
wonder whether she had the ability to succeed in a health care


To promote safety as new trainees carry out
patient care procedures, schools and health care facilities must
promote a safety climate

  • Emphasizing the importance of checking
    and double checking, and recognizing the importance of redundancies
    in preventing human error;
  • Collaborating in providing a practice
    environment that promotes student learning and patient safety
  • Accepting that excellent student
    learning is a shared responsibility and is a sound investment for
    quality and safety of patient care in the future; and
  • Modeling the best practices for
    protecting patients from error, even when these practices are not
    the most efficient.

Mary A. Blegen, RN, PhD
Professor in Community Health System
Director of the Center for Patient Safety
University of California, San Francisco School of Nursing

Ginette A. Pepper, RN, PhD
Professor and Associate Dean for Research
Helen Bamberger Colby Chair in Gerontological Nursing
University of Utah School of Nursing


1. Craven RF, Hirnle CJ. Medication
administration. In: Fundamentals of Nursing: Human Heath and
Function. Philadelphia, PA: Lippincott Williams & Wilkins;
2003:chap 27.

2. Potter PA, Perry AG. Medication
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Mosby; 2005:chap 34.

3. Cohen MR. Medication Errors. Boston, MA: Jones
and Bartlett; 1999:chap 11.

4. Recommendations to enhance accuracy of
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Accessed April 27, 2006.

5. Computer entry a leading cause of medication
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Pharmacopeia; December 20, 2004.

6. Mason D. Security lapse. AHRQ WebM&M
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7. Wachter RM. Low on the totem pole [Spotlight].
AHRQ WebM&M [serial online]. December 2005. Available at:
Accessed April 27, 2006.