In administering medication to a patient, the nurse sees that the medication administration record indicates the dose amount to be 5 mg. Because the dose seems high, the nurse decides to double check the order and confirms that the dose was transcribed incorrectly; that the dose was supposed to be 0.5 mg. Hospital policy is that when transcribing a dose, staff are required to always use a zero before a decimal when the dose is less than a whole unit. This is a national safety standard. This could have been a medication error that could have caused serious harm to the patient. The nurse wants the unit to be safe but doesn’t want anyone to get in trouble for the mistake.

1.

What cues might the nurse identify and consider in this situation?

2.

What hypothesis will the nurse consider based on the available information?

3.

How should this be addressed in a culture of safety?

4.

What can the nurse do to protect patients from medication errors and promote safe medication practice on the unit?