Managing Medication Errors – A Qualitative Study

1 174 MEDSURG Nursing June 2005 Vol. 14/No. 3 pamela StetinaMichael GrovesLeslie PaffordManaging Medication Errors A Qualitative StudyPamela Stetina, MN, RN,is an Assistant Professor of Nursing, Texas A&MUniversity, Corpus Christi, TX, and a Doctoral Student, Texas Women s University,Houston, TX. Michael Groves, RN, MGA, CNAA,is a Chief Nursing Officer, City Hospital, Inc.,Martinsburg, WV, and a Doctoral Student, Texas Woman s University, Houston, Pafford, MSN, RN, FNP, is a Doctoral Student, Texas Woman s University,Houston, Errors continueto be a significant issue affect-ing patient safety in UnitedStates hospitals. The re-searchers conducted a qualita-tive Study to explore the under-standing and management ofmedication Errors by practic-ing nurses.

2 The results indicat-ed a belief that late medicationadministration does not alwaysconstitute an error, the use ofnursing judgment helps deter-mine when and if medicationshould be given, and anincreased reliance upon com-puterized and systematicchecks put into place in healthcare Institute of Medicine reports 44,000 to 98,000 people die in hospitalsannually as a result of medical Errors that could have been prevented(Kohn, Corrigan, & Donaldson, 2000). Medication Errors accounted for7,391 deaths in 1993, compared to 2,876 deaths in 1983 (Kohn et al., 2000).These Medication Errors and the adverse reactions connected with themresult in increased length of stay, increased cost, patient disability, anddeath.

3 The Medication delivery process is complex and involves hand-offsbetween many individuals and departments. Errors may occur at any ofthe process steps: prescription, transcription, dispensing, or administra-tion. Most error-reporting systems rely on voluntary self-reporting andare imbedded into what remain largely punitive management widely report reluctance to disclose Medication Errors , particu-larly if an error does not result in patient harm (Wakefield, Wakefield,Uden-Holman, & Blegen, 1996; Walker & Lowe, 1998). The purpose of thisphenomenologic Study was to explore the management of medicationerrors by practicing nurses by examining the ways that nurses definemedication Errors and make decisions regarding the reporting of med-ication Errors , and how Medication Errors affect nurses day-to-day prac-tice.

4 Results from this Study may help nurses and hospital administratorsunderstand the reluctance to report Medication of the LiteratureSeveral studies have explored nurses experience with medicationerrors. These studies demonstrate inconsistency with the definition ofMEDSURG Nursing June 2005 Vol. 14/No. 3175medication Errors and with thelikelihood of reporting someevents even when they are identi-fied as Errors . Osborne, Blais, andHayes (1999) surveyed registerednurses on medical-surgical unitsin a 700-bed community hospitalin Florida. The Study wasapproved by institutional reviewboards of the hospital and theaffiliated university of theresearchers.

5 Surveys were distrib-uted to 92 full-time and part-timeRNs who administered medicationat the hospital; 57 surveys werereturned ( ). Participants wereasked to rank 10 perceived causesof Medication Errors . The authorsfound that the top three perceivedcauses of Medication Errors werefailure to compare the patientidentification band with the med-ication administration record( , n=20), nurse fatigue( , n=14), and illegible hand-writing by the prescriber ( ,n=7). Additionally, the authorsdemonstrated that given fiveadministration scenarios about amissed Medication dose (a latedose, a purposely omitted dose, awrong intravenous total parenter-al nutrition rate, and a pain med-ication 1 to 2 tablet dose rangewhere the nurse gave a secondtablet prior to the schedule time)

6 ,participants were unable to reachuniversal agreement regarding theidentification of the scenario as amedication another Study of 43 nursesfrom six clinical areas originallyselected to trial a new medicationincident reporting form in anAustralian hospital, participantswere presented with 12 scenariosand asked to identify whetherthey would report a medicationincident (Walker & Lowe, 1998).Only one scenario (giving meto-prolol [Lopressor ] to the wrongpatient) was identified as a med-ication error by all aspirin to thewrong patient (98%), giving thewrong dose of furosemide(Lasix ) (97%), giving penicillin toa patient with an allergy to thedrug (97%), and giving a drug viathe wrong route (95%) alsoranked as reportable 53% of the nurses surveyedindicated that giving IV digoxin(Lanoxin ) an hour late constitut-ed a reportable Medication inci-dent.

7 The participants also wereasked to participate in focusgroup discussions. Themes thatemerged from the discussionsincluded self-preservationand itdepends (on the circumstances).Comments related to self-preser-vation involved fear of being rep-rimanded and concerns aboutincriminating a colleague. Com-ments about circumstancesinvolved nurses assessment ofthe entire situation to determine ifan incident truly et al. (1996) studied1,384 nurses in 24 acute care hos-pitals in Iowa using a 16-itemLikert survey designed to indicatelevel of agreement (1 to 6, fromstrongly disagree to stronglyagree) about why medicationerrors may not be reported.

8 Thesurveys were distributed by theindividual hospitals, but returneddirectly to the analysis identified fourpossible barriers to the reportingof Medication Errors by may not be reported if thenurse is fearful of reporting con-sequences, if there are negativeresponses or the absence of posi-tive responses from administra-tors, or if the effort required toreport the error is too great. Thenurse s perception of the event asan error also was implicated as abarrier to an ethnomethodologicapproach, Baker (1997) studiednurses on three different nursingunits in New South Wales,Australia, over an 18-week Study involved observation,documentation, analysis, and vali-dation of results.

9 Baker discov-ered that nurses believed it wasnot an error if the nurse could cor-rect the situation safely, if thepatient status required a change,or in emergency the situation involvedaltering time frames in order toget the patient back on scheduleor to resolve clerical status included situationssuch as patients who neededmedications adjusted because oftests or because the patient need-ed uninterrupted sleep. Finally, itwas well understood that medica-tions may be given late if thenurse was in an emergency , Robinson, and Man-drack (2003) analyzed 775 respons-es to a poll. The authors noted 36%of nurses indicated that they hadnot reported a Medication errorbecause they felt that to do sowould have been personally orprofessionally damaging.

10 Also,nurses evidently interjected judg-ment into the decision to reporterrors. If the nurse believed thatthe practice deviation was rea-sonable given the circumstancesand the patient suffered no harm,then the event was likely not to beperceived as an error and wouldnot be reported. An example of adeviation that was unlikely to bereported was the administrationof an antibiotic shortly after theexpiration of the agency-imposedtimeframe for on-time adminis-tration. Nurses were also some-what unlikely to report the errorsof others, indicating that theywould never report the error ofphysicians (19% of the time),pharmacists (14% of the time), orother nurses (9% of the time).