Medication errors: more basic than a system issue

E Carol Polifroni
John McNulty
Lynn Allchin

Document Type Article


The Institute of Medicine's 2000 report drew attention to both U.S. health care agencies and the medication errors that occur within them. However, this attention focused on a more basic and fundamental issue within the medication error concern: nurses' mathematical skills and competence. This article describes a nationwide study assessing processes to validate mathematical skills for medication administration. Practices within educational and acute care institutions are explored, and recommendations for future action are noted with a call for 100% accuracy on all mathematical examinations for medication administration.