MEDICATION ADMINISTRATION ERRORS: …

1 33 Australian Journal of Advanced Nursing 2006 Volume 23 Number 3 ABSTRACTO bjective:This paper surveys current literature related tomedication ADMINISTRATION errors , the role of nurses in such errors , and current initiatives that areunderway within New Zealand to address this aspectof patient :The literature review focused on research thatprimarily addresses the issues related to medicationsthat arise in tertiary care argument: MEDICATION ADMINISTRATION errors are reported tooccur in one in five MEDICATION dosages. Such eventshave long been scrutinised, with the primary focusbeing the practice of nurses and their role inmedication error.

2 Analysis of such events frequentlyidentifies the nurse as the deliverer of unsafe , over the past few years a shift in howmedication errors are understood has led to theidentification of systems-related issues that contributeto MEDICATION :Initiatives such as the Quality and Safe Use ofMedicines raise the opportunity to address some ofthe safety related issues with a view to enhancingpatient safety. A call for nurses to pre-emptively driveand contribute to these initiatives, along with thedevelopment of nursing led research, is issue of MEDICATION ADMINISTRATION (MA) withinthe acute-care setting has long been the focus of scrutinyand research, in part because MEDICATION administrationerrors (MAE) contribute directly to patient morbidity andmortality (Tissot et al 2003; Barker et al 2002a; Schneideret al 1998).

3 A desire to provide patients with optimum andsafe care fuels practitioners and academics alike to createstrategies to reduce the likelihood of ADMINISTRATION errorsoccurring. However, MAE continue to development of the Safe and Quality Use ofMedicines group in Australia in the early 1990s promptedAustralian practitioners to review historically-acceptedpractices surrounding MA and re-configure how theyconceptualised the safe use of medicines (Hunt and Parks1999). In late 2003, New Zealand health care practitionersbegan to adopt a similar strategy of the same name foraddressing MEDICATION issues in relation to patient strategies provide nurses with a unique opportunityto contribute to practice initiatives at the national policylevel and enhance the quality of patient care.

4 It is crucialthat nurses actively engage in this debate and contributeto the body of knowledge in this paper examines the issue of MA in the acute-caresetting. It highlights: how MAE are defined in theliterature, which has historically positioned nurses asincompetent and in need of remedial assistance; commonreasons for MAE; and strategies for the prevention ofsuch events. Literature that speaks specifically to the NewZealand context is considered, and a critique of currentunderstandings of nursing practice in relation to MA isoffered. The article concludes with a call for research onMA that is focused on, and driven by, nurses.

5 SEARCH METHODThe search methods employed for this literature reviewincluded both nursing and medical databases. SpecificKaren McBride-Henry, BScN(hons), MN, PhD Research Fellow,Clinical Effectiveness Unit (Nursing and Midwifery), Capital &Coast District Health Board, Wellington South, New Zealand Foureur, BA, GradDipClinEpidem, PhD, ClinicalProfessor, Graduate School of Nursing & Midwifery, VictoriaUniversity of Wellington, Wellington New ZealandAccepted for publication May 2005 MEDICATION ADMINISTRATION errors : UNDERSTANDING THE ISSUESSCHOLARLY PAPERKey words: quality and safe use of medicines, professional practice, nursing research, literature review Australian Journal of Advanced Nursing 2006 Volume 23 Number 3databases accessed included: Cumulative Index to Nursingand Allied Health (CINAHL), Cochrane Database ofSystematic Reviews, Medline, Proquest, Web of Science,Blackwell Synergy and EBSCO megafile.

6 The key wordsemployed for the search were: MEDICATION ADMINISTRATION , drug ADMINISTRATION , MEDICATION ADMINISTRATION errors , MEDICATION safety , quality use of medicines , nursingand medicines , patient safety , incident reporting ,quality improvement strategies , and organisationalsafety . The literature was limited to English based of MEDICATION ADMINISTRATION errorsMultiple definitions of what constitutes a MAE existin published research and literature. One definitionfrequently employed by medical doctors of MAE is anydeviation from the physician s MEDICATION order as writtenon the patient s chart (Headford et al 2001; Mark andBurleson 1995), which fails to consider that prescribingerrors do contribute to MAE (Davydov et al 2004;Headford et al 2001; Wilson et al 1998).

7 However, the definition typically cited in literature thatis authored by nurses is that of Wolf (1989), who definesMAE as mistakes associated with drugs and intravenoussolutions that are made during the prescription,transcription, dispensing, and ADMINISTRATION phases ofdrug preparation and distribution (Wolf 1989, ).These errors can be classified as either acts ofcommission or omission, and may include the following:wrong drug; wrong route; wrong dose; wrong patient;wrong timing of drug ADMINISTRATION ; a contra-indicateddrug for that patient; wrong site; wrong drug form; wronginfusion rate; expired MEDICATION date; or prescriptionerror.

8 Such errors can occur in either an intentional orunintentional manner (Wolf 1989). MEDICATION error ratesThe manner in which MAE rates are determined variesgreatly and is dependant on the method of measurementemployed to assess the error rates. However, observationsof practice are considered to be the most accurate way ofmeasuring the occurrence of MAE (Thomas and Peterson2003; Barker et al 2002b; Flynn et al 2002). Two such observational studies found that MAE ratesin the acute-care setting varied between (Tissot etal 2003) and (Schneider et al 1998). Themedication error rate for intravenous medications issignificantly higher than other types of medications, withresearchers observing preparation error rates of 26% andadministration error rates of 34% (Wirtz et al 2003).

9 Thetotal of all observed MEDICATION errors indicates thaterrors occur in almost one out of every five doses (Barker et al 2002a). Research that has assessed the errorrates during either the prescribing, preparation oradministration phases of MEDICATION handling is furtherdescribed in table one. SCHOLARLY PAPER34 Table 1: Research measuring MEDICATION error rates Participants/settingMethod of measurementPrescribingPreparation AdministrationNurses: geriatric &ObservationalNot observedNot :100cardio-thoracic units(Tissot et al 2003)Nurses: paediatric ICUO bservationalNot observed23 :100(Schneider et al 1998)Junior medical staffProspective :100 Not observedNot observed(Davydov et al 2004)Clinical charts and incident Chart audit8:100 :100 reports (Headford et al 2001)Analysis of incident reports(of all incidents)(Ratio of incident (Ratio of incident classification)classification)Nurses & doctors.

10 ObservationalNot observed26:10034:100intravenous MEDICATION in acute care (Wirtz et al 2003)Medical and surgical units in Prospective cohort study39:100 Not measured38:100two tertiary-care hospitals(Leape 1995)Doctors, nurses, pharmacist: Prospective cohort study68:1007:10025:100tertiary-care hospital(Wilson et al 1998)Doctors, nurses, pharmacist: Retrospective analysis of22:10015:10032:100tertiary-care hospitalincident reports(Ashcroft et al 2003)All HCP in PACU Secondary analysis of :100(Hicks et al 2004)MEDMARX databaseAustralian Journal of Advanced Nursing 2006 Volume 23 Number 3 When addressing the issue of MAE rates, researchersreturn to standard categories for describing the variousways in which errors occur.