Reducing medication errors in nursing practice

CANCER NURSING PRACTICE February 2015 | Volume 14 | Number 1 29
Continuing professional development
Reducing medication errors
in nursing practice
Abstract
Medication errors remain one of the most common causes of unintended harm to patients. They contribute
to adverse events that compromise patient safety and result in a large financial burden to the health service.
The prevention of medication errors, which can happen at every stage of the medication preparation and
distribution process, is essential to maintain a safe healthcare system. One third of the errors that harm patients
occur during the nurse administration phase: administering medication to patients is therefore a high-risk activity.
This article highlights factors that contribute to medication errors, including the safety culture of institutions.
It also discusses factors that relate specifically to nurses, such as patient acuity and nursing workload, the
distractions and interruptions that can occur during medication administration, the complexity of some medication
calculations and administration methods, and the failure of nurses to adhere to policies or guidelines.
Correspondence
[email protected]
Linda Cloete is a lecturer at the
faculty of nursing and health,
Avondale College of
Higher Education, Sydney,
Australia
Conflict of interest
None declared
Keywords
Drug calculations, medication
errors, nursing systems,
patient safety
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This article was originally
published in Nursing Standard
(2015) 29, 20, 50-59.
CNP1178 Cloete L (2015) Reducing medication errors in nursing practice.
Cancer Nursing Practice. 14, 1, 29-36. Date of submission: August 19 2014.
Date of acceptance: October 13 2014.
Aims and intended learning outcomes
This article provides insight into factors that contribute
to medication administration errors and that can result
in poor patient safety outcomes. After reading this
article and completing the time out activities you should
be able to:
â– â–  List potential risks that contribute to
medication errors.
â– â–  Explain how a number of unrelated risks, when
allowed to coexist, may result in adverse events
in the delivery of health care.
â– â–  Discuss ways to limit risks of medication errors in
your practice team.
â– â–  Reflect on contributions that could be made towards
the development of a safe reporting environment
for fostering the growth of knowledge and
achieving strategies that minimise the potential for
medication errors.
â– â–  Create a list of resources that promote active
involvement in the prevention of medication errors
and contribute to safe practice.
Introduction
Medication errors remain one of the most common
causes of harm to patients (Roughead et al 2013). A
medication error is defined as a preventable event related
to medication which results in ‘a failure in the treatment
process that leads to, or has the potential to lead to,
harm to the patient’ (Ferner and Aronson 2006). The
medication treatment process includes all aspects of
medication handling (Aronson 2009,
National Coordinating Council for Medication Error
Reporting and Prevention 2014).
A review of medication error incidents reported
between 2005 and 2010 to the National Reporting
and Learning Service indicated that 526,186 such
incidents had occurred in England and Wales over this
period (Cousins et al 2012) (Table 1, page 30). A
total of 86,821 (16%) of these incidents caused actual
patient harm, of which 822 (0.95%) resulted in death
or severe harm (Cousins et al 2012). The cost to the
NHS of hospital admissions related to medication errors
in 2007 was £770 million and between 1995 and
2007 £5 million was spent on litigation costs (Frontier
Economics 2014). In the UK, one third of medication
errors occurring in general medical practices related
to prescribing errors. Many of these were the result of
poor communication, particularly with regard to the
prescription of antibiotics to which patients are known
to be allergic (National Patient Safety Agency (NPSA)
2007). Medication errors contribute to adverse events
that compromise patient safety and place a large
financial burden on health systems (Roughead et al
2013). In addition to the financial costs, individual
30 February 2015 | Volume 14 | Number 1 CANCER NURSING PRACTICE
Continuing professional development
patients and their significant others are affected
physically, emotionally and psychologically when
errors occur (Deans 2005). Therefore, the prevention
of medication errors is essential to maintaining a safe
healthcare system (Roughead et al 2013).
Medication processes are complex in nature,
involving multiple interactions, and are high-risk
activities (Nursing and Midwifery Council (NMC) 2010).
Although errors occur at every stage of the medication
preparation and distribution process (Aspden et al 2006,
McBride-Henry and Foureur 2006, Maricle et al 2007,
Biron et al 2009), one third of those that harm patients
are attributed to the administration phase (Leape et al
1995). Most medication administrators are nurses and,
therefore, when errors occur, nurses are often deemed
accountable (Burke 2005). Medication administrators
can provide a safeguard against errors made at any
of the previous stages, however, and are thought to
intercept around 86% of errors made by prescribers
or pharmacists (Leape et al 1995). Therefore, nurses
provide a safety defence against medication errors but,
at the same time, have the potential to place patients at
risk (Pape et al 2005).
Table 1 Patient safety incident and medication incident reports (2005-2010)*
Healthcare sector Total number of
incident reports
Number of
medication
incident reports
Medication incidents
as a percentage of
total incident reports
Acute/general hospital 3,921,212 394,951 10.07
Mental health service 754,812 48,951 6.49
Community nursing, medical and therapy
service, including community hospital
542,323 48,594 8.96
Learning disabilities service 155,914 8,154 5.23
General practice 22,587 5,358 23.72
Community pharmacy 19,696 19,245 97.71
Ambulance service 18,415 712 3.87
Community and general dental service 2,560 133 5.20
Community optometry/optician service 82 4 4.88
Not stated 398 84 21.11
Total 5,437,999 526,186 9.68
*Recorded by the National Reporting Learning Service for each healthcare sector in England and Wales. Cousins et al 2012)
This article discusses types of medication errors and
the contributing factors that occur in clinical practice.
It then concentrates on specific problems that nurses
can encounter in the administration process.
Errors and contributing factors
The types of errors that can occur are listed in Box 1
(Lassetter and Warnick 2003, McBride-Henry and Foureur
2006, Biron et al 2009). The two most common
medication errors are incorrect time of administration and
medication omission for no acceptable clinical reason
(Barker et al 2002).
Now do time out 1.
1 Medication delay Time outA patient’s intravenous antibiotic is delayed
by two hours because the patient was away
from the ward undergoing an investigative
procedure. Would this delay constitute
a medication error? Discuss this with a
colleague or describe strategies that could
be employed to prevent such an occurrence.
CANCER NURSING PRACTICE February 2015 | Volume 14 | Number 1 31
2 Patient factors Time outReflecting on your practice, can you
remember a circumstance where any of the
patient factors given in Box 2 could have
contributed to a medication error? Consider
the strategies that could be used to minimise
the risk of an incident for each factor.
Various studies have identified factors that contribute
to medication errors; these are broadly classified as
patient, system and personal factors (Grandell-Niemi et al
2003, Greenfield 2007, Mrayyan et al 2007, Wright
2007). Patient factors relate to the characteristics
or attributes of patients that place them at risk
of experiencing a medication error (World Health
Organization (WHO) 2009a) (Box 2).
Now do time out 2.
System and personal factors, respectively, relate to
institutional and individual practitioner characteristics that
contribute to the relative risk of medication errors. System
factors include the safety culture of an organisation,
management and leadership, workplace communication
and workplace policies and procedures. Examples include
addressing the educational needs of staff (including
agency nurses) and having accessible, succinct, stepby-step guidelines and protocols for the operation of
equipment. Personal factors include the cognitive ability
and skill, situational awareness, decision-making ability
and personal resources (including responses to stress and
fatigue) of individual practitioners (WHO 2009b).
The system approach, while acknowledging the
individual practitioner’s role in, and responsibility for,
errors, recognises that many medication errors could
be prevented by greater attention being placed on the
system and less on apportioning blame to individuals
(Reason 1990, Biron et al 2009). Nurses, however,
should continue to reflect critically on the potential for
improving their own practice. The following sections will
discuss the system and personal factors that may result in
medication errors.
Organisational safety culture
A safety culture in healthcare systems comprises
enlightened leadership, teamwork and a patient-centred
approach to care (Sammer et al 2010). Organisations
involved in highly complex, technological processes
demand a failure-free operational standard from their staff.
Frankel et al (2006) summarise the attributes necessary
to achieve this as ‘mindfulness’. Such attributes include:
â– â–  An awareness of the possibility of failure.
â– â–  Respect for all colleagues.
â– â–  An ability to adjust and remodel plans in
unforeseen circumstances.
â– â–  An ability to accommodate the bigger picture, while
maintaining focus on an isolated task.
While a culture of safety is partially determined by
organisational structure and leadership, the unit manager
plays a significant role in the effective implementation of
the safety culture in a nursing team (Mayo and Duncan
2004, Ulanimo et al 2007, Valentin et al 2009).
Until recently, nurses have focused on their individual
actions in efforts to promote safety and prevent harm to
patients (Mayo and Duncan 2004, Ulanimo et al 2007,
Valentin et al 2009). While this remains good practice,
nurses should also evaluate the way they function
in teams to ensure that the collective systems and
processes of practice are safe and to support and educate
inexperienced colleagues (Mayo and Duncan 2004,
Ulanimo et al 2007, Valentin et al 2009).
An emotionally unsafe environment (that is, one
led by managers who believe in demonstrating power
and control over employees, who do not recognise
individual needs or who are intimidating), along with
fear of discipline, can inhibit the reporting of errors by
nurses (Mayo and Duncan 2004, Ulanimo et al 2007,
Valentin et al 2009). In a study of 983 nurses, 76.9%
Box 2 Patient factors that increase the risk of medication errors
Box 1 Types of medication error
â– â–  Wrong time of administration or delayed
administration.
â– â–  Medication omission without acceptable
clinical reason.
â– â–  Unauthorised medication administration.
â– â–  Wrong dose administered.
â– â–  Extra unauthorised dose administered.
â– â–  Medication administered via incorrect route.
â– â–  Medication administered at the incorrect rate.
â– â–  Medication administered in incompatible fluid or in
conjunction with another incompatible medication.
â– â–  Medication calculation error.
â– â–  Medication administered to the incorrect patient.
â– â–  Allergy-related error.
(Lassetter and Warnick 2003, McBride-Henry and
Foureur 2006, Biron et al 2009)
Multiple medication use:
â– â–  Complex disease process.
â– â–  Multiple medical problems.
â– â–  More than one prescribing doctor.
Poor communication:
â– â–  Children and babies.
â– â–  Confused or unconscious state.
â– â–  Language difficulties.
Passive involvement:
â– â–  Culturally determined passive
relationship with health professionals.
â– â–  Lack of interest in being informed
about health and medications.
Complicated drug calculation
requirement:
â– â–  Titrated medications.
â– â–  Weight-based medications
(children and babies). (World Health Organization 2009a)
32 February 2015 | Volume 14 | Number 1 CANCER NURSING PRACTICE
Continuing professional development
thought that medication errors were unreported because
of fear of a negative reaction from the unit manager
(Mayo and Duncan 2004). Organisations that aim to
understand fully the factors, systems and processes
that lead to medication errors and to identify error
minimisation strategies need staff to feel free to voice
concerns in a safe environment, and admit to errors and
the need for development (Frankel et al 2006).
Effective communication is a key element of the safety
culture in an organisation, particularly the communication
between and within multidisciplinary teams in relation
to medication processes (Savvato and Efstratios 2014).
Nurses are directly involved in preventing errors at
administration level and are often integral to prompting
prescriptions, advising on dosages during the prescription
writing phase, informing pharmacy about incorrectly
dispensed medication, detecting errors and taking
corrective action in medication preparation before
administration (Popescu et al 2011).
Inexperienced nurses are particularly vulnerable to
errors associated with miscommunication, because
of low levels of anticipation or awareness of the
potential for error. They are therefore less likely than
their experienced colleagues to seek clarification either
through verbal communication with colleagues or from
written information (Kazaoka et al 2007, Savvato and
Efstratios 2014). Experience promotes anticipation and
early detection of errors (Seki and Yamazaki 2006).
Therefore, ensuring an adequate skill mix on shifts may
help prevent medication errors (Tang et al 2007).
Communicating with and educating patients about
their medications during the administration process can
result in individuals being better informed about and
more involved with their medicines, thereby improving
the quality and safety of medication administration
(Popescu et al 2011). This may be particularly the case
in community settings, such as in a patient’s home,
where the most common reason for medication errors
relates to administration. Therefore, helping patients to
understand and manage medication administration safely
can contribute to reducing errors (NPSA 2007).
Now do time out 3.
Interruptions and distractions
Higher medication error rates are associated with greater
levels of interruptions during medication administration
(Westbrook et al 2010). Indeed, interruptions at this
stage are one of the main contributing factors to errors
(Mayo and Duncan 2004, Deans 2005, Hopp et al 2005,
Ulanimo et al 2007, Westbrook et al 2010, Ozkan et al
2011). In this context, interruptions are defined as a
halt in the primary activity being performed – medicine
administration – to carry out a secondary task, resulting in
nurses having to manage a number of tasks simultaneously
(Mrayyan et al 2007, Petrova 2010, Ozkan et al 2011).
Distractions, such as noise, can be ignored or processed
concurrently with the primary task; however, they may
also contribute to errors and act as a precursor to an
interruption (McFarlane and Latorella 2002).
Medication administration includes components of
both skill-based and knowledge-based task requirements.
Skill-based tasks require attention to be focused on the
activity being performed, to ensure successful completion
(Reason 1990). Interruptions that divert attention can
hamper skill-based performance (Reason 1990),
while knowledge-based tasks rely on conscious analytical
processes that can be disturbed by competing demands
for cognitive resources, fatigue and distractions such as
noise (Wickens and Hollands 2000).
When a number of patient activities occur
simultaneously, nurses are involved in complex
decision making to prioritise activities. Many competing
activities have the potential to result in distractions and
interruptions that can interfere with a primary task and
may contribute to errors. Nurses are often required to
choose between attending to, ignoring and delaying
attending to distractions when undertaking medication
administration, which may result in the nurse anticipating
potential distractions, prioritising one task over another or
delegating a secondary task (Popescu et al 2011).
The most common source of interruption is from
another nurse requiring face-to-face communication
(Hedberg and Larsson 2004, Spencer et al 2004,
Alvarez and Coiera 2005, Popescu et al 2011). Such
interruptions frequently occur during direct patient care
activities, and the activity interrupted most often is that
of medication administration (Hedberg and Larsson
2004). Common locations for interruptions to occur
are medication rooms and open spaces where nurses
may be viewed as being more accessible (Hedberg and
Larsson 2004, Bennett et al 2006). Areas that allow
for conversation result in higher levels of distraction and
interruption (Popescu et al 2011).
Other sources of distraction and interruption include
patients (Hedberg and Larsson 2004, Lyons et al
2007), technical sources (for example, alarms) and
operational failure (for example, the unavailability of
a medication or infusion device required for medicine
administration) (Hedberg and Larsson 2004, Tucker
and Spear 2006). Operational failure regularly results in
drugs being omitted or administered late (Popescu et al
2011). Minimising the frequency of interruptions may
3 Safe reporting environment Time outList any strategies that foster a safe
reporting environment in your workplace.
How could you personally contribute towards
implementing them?
CANCER NURSING PRACTICE February 2015 | Volume 14 | Number 1 33
limit the number of medication errors. The NPSA (2012)
recommends that institutions develop policies and
procedures to minimise interruptions during administration
of medicines. Solutions to minimising interruptions
include: the creation of interruption-free zones of work
– thus limiting casual conversations in certain work
areas, wearing ‘Do not disturb’ safety vests or armbands
and using ‘Do not disturb’ signs to indicate the need
for interruption-free work (Pape et al 2005, Biron et al
2009). Other suggestions include the allocation of specific
times during shifts when nurses can administer medication
free from clerical interruptions and postponing non-urgent
patient care tasks (Savvato and Efstratios 2014).
Any intervention that leads to fewer distractions
could ultimately enable nurses to focus more on the
task that they are performing, complete the task in good
time and create less work-related stress and greater job
satisfaction (Pape et al 2005).
Therefore, nurses should learn to recognise
the potential for making errors during medication
administration and take active steps to avoid distractions
and interruptions (Palese et al 2009). They should learn
to recognise when it is appropriate to be interrupted – for
example, to attend to a patient alarm or a patient whose
condition is deteriorating – and when it is preferable
to defer the interruption – for example, responding to
clerical enquiries. This requires exercising critical thinking
and making appropriate clinical judgements, which are
fundamental responsibilities of the professional nurse
(Jones and Treiber 2010). Nurses should also be made
aware of their potential to distract and interrupt other
nurses and work towards minimising such occurrences.
Now do time out 4.
Shift length, patient acuity and workload
Research suggests that the number of hours nurses
work, length of shifts, patient acuity and high workloads
result in nurse fatigue (Suzuki et al 2005, Ulanimo et al
2007). Nurses who engage frequently in competing
activities as a result of high workloads and the acute
nature of patients’ conditions are more likely to
experience distractions and interruptions, focus poorly on
work-related activities and potentially make more errors
(Tang et al 2007, Hewitt 2010).
The likelihood of errors has been found to be
three times higher when staff work 12.5 or more hours
in a shift (Rogers et al 2004), and nurses are two and
a half times more likely to suffer burnout and job
dissatisfaction when regularly working shifts of ten hours
or longer (Stimpfel et al 2012).
While employers are bound by statutory requirements
and organisational policies to limit shift length and
hours of work per week, it remains the responsibility
of individual practitioners to practise within these
boundaries to remain safe (NMC 2010, Fair Work
Ombudsman 2014, Royal College of Nursing 2014).
Compared with day workers working regular
hours, those working shifts, especially at night, have
a significantly higher risk of accidents and near-miss
events. This is the result of lower alertness and a greater
tendency to experience drowsiness, both of which affect
cognitive function (Barger et al 2009). Staff sleeping
during the daytime can optimise sleep time by avoiding
exposure to bright light and stimulants, keeping the
room dark and using earplugs. Before starting a night
shift, staff can increase their wakefulness by exposing
themselves to bright light; they can also make use
of short occasional nap periods when on breaks
(Barger et al 2009, Rajaratnam et al 2013).
Access to information and guidelines
A number of international studies have found that nurses
prefer to approach colleagues for information to aid
decision making rather than to access evidence-based
resources from reliable databases (Thompson et al
2001, Estabrooks et al 2003, Pravikoff et al 2005,
Kosteniuk et al 2006). Reasons for this include
convenience and time efficiency, a perceived lack of
computer skills and low confidence levels when using
online records that require search word and phrase
selection (Thompson et al 2004, Dee and Stanley 2005).
A lack of convenient access to policies and guidelines
for medication administration is likely to result in poor
information-seeking habits, which may contribute in turn
to medication errors (O’Leary and Mhaolrúnaigh 2012).
A lack of information, training and preparation with
regard to using infusion devices can contribute to errors
(Mayo and Duncan 2004, Ulanimo et al 2007, Jones
and Treiber 2010).
Environmental factors
Environmental characteristics that can lead to problems
during administration of medications include poor lighting,
high noise levels, restricted storage space resulting in
cluttered work surfaces, poor layout of medication rooms,
a lack of space for preparing and charting medications,
and in particular a lack of privacy in medication rooms.
Each of these factors can be associated with a higher
incidence of fatigue, stress, distraction and interruptions
(Mahmood et al 2011, Savvato and Efstratios 2014).
Environmental factors, therefore, should be considered
4 Interruption Time outConsider what activities can be sources
of interruption during medication
administration. Describe strategies that could
be used to reduce the frequency of such
interruptions. Outline a number of strategies
that could result in fewer distractions.
34 February 2015 | Volume 14 | Number 1 CANCER NURSING PRACTICE
Continuing professional development
when planning strategies to minimise medication errors
(Savvato and Efstratios 2014).
Drug calculation and administration
Studies have shown that nurses have poor drug
calculation skills, which could account for 10-20% of
medication errors (Wright 2004, 2005). In addition,
it has been reported for more than four decades that
nursing students have difficulty with mathematical tasks
such as unit conversions, dosage calculations and fluid
monitoring (Bindler and Bayne 1984, Worrell
and Hodson 1989, Sandwell and Carson 2005).
Two skills have been identified as necessary for
accurate drug calculation: basic mathematical and
computational aptitude, and, the ability to understand
clinical information well enough to formulate correctly a
suitable mathematical problem to calculate drug dosage
(Wright 2007). According to Vagliardo and Schmittau
(2008), it is important for practitioners to be able to
estimate, to correctly interpret graphs, proportions, ratios
and tables, and to be resourceful in problem solving; good
mathematical understanding means not being dependent
on a calculator.
There appears to be a significant correlation between
a positive attitude towards mathematics, self-efficacy
(the belief in one’s own ability to complete tasks and
reach goals) and performance, with feelings of selfefficacy being a stronger predictor of performance than
attitude to mathematics (Hackett and Betz 1989, Ma
and Kishor 1997, Nicolaidou and Philippou 2003).
Mathematical-related anxiety is correlated inversely to
self-efficacy for complex mathematical tasks, where drug
calculations are perceived as difficult (Walsh 2008).
Therefore, nurses may be likely to perform less well on
complex drug calculations as a result not only of the
complexity of a task but also the level of their perceived
self-efficacy in relation to undertaking the calculation.
Levels of confidence and self-efficacy in completing
basic and complex tasks can improve with mathematical
practice (Walsh 2008).
Now do time out 5.
Understanding and reporting errors
It is important to ascertain how errors occur, and
this is primarily achieved through adequate reporting
(Hewitt 2010). The first step in planning strategies to
reduce errors is to obtain a clear understanding of what
constitutes an error (McBride-Henry and Foureur 2006).
A mixed-methods study on medication errors in a district
general hospital in south west England found that there
was confusion among nurses as to what constituted a
medication error and which incidents should be reported
to a physician or nurse manager (Gladstone 1995).
For example, less than 20% of the 81 nurses who
responded to a questionnaire identified the following as
medication errors:
â– â–  A patient having missed an antibiotic dose due to the
fact that he was away from the ward for three hours.
â– â–  A dose of medication delayed by 45-60 minutes.
â– â–  A dose of nebulised medication at 2am omitted
because the patient was sleeping.
Raising awareness by disseminating information about
factors that are likely to increase the possibility of errors
and what constitutes an error may be useful in improving
nurse vigilance (Savvato and Efstratios 2014).
Failure to follow policy or guidelines
One of the more common personal contributors to
medication error is a failure to adhere to professional
and institutional policies or guidelines (NMC 2010),
in particular a failure to check the ‘five rights’ (right
patient, right medication, right dose, right route, right
time) (Tang et al 2007, Ulanimo et al 2007). Neglecting
these checks has been shown to contribute to medication
errors (Pape et al 2005, Fogarty and McKeon 2006).
Failure to check identity bands was found by
Westbrook et al (2010) to be the most common deviation
from procedural policy. Failure to watch patients take
medication and signing charts before medication was
consumed were also common. Reasons given for
deviations from policy were mostly to save time. Such
findings show a lack of insight into the necessity to check
a medication chart against a patient’s identity band. It has
been suggested that nurses may not value the practice of
checking name bands or that the practice loses importance
when the nurse is no longer being supervised (Hewitt
2010, Jones and Treiber 2010). It could be argued that
nurses, having worked previous shifts and having attended
to the same patients, would correctly identify a patient by
sight. However, not implementing the process of checking
identity bands prevents nurses ensuring that a medication
chart belongs to the correct patient.
Nurse managers must ensure that guidelines and
policies are available and accessible, and encourage
their implementation. Creating suitable additional
defence barriers (for example, double checks for highrisk situations such as paediatric medications, unusual
prescriptions, similar names or packaging) could minimise
errors; however, it has also been noted that single checks
can result in fewer nurse interactions and thus fewer
distractions (Biron et al 2009, Popescu et al 2011,
Savvato and Efstratios 2014).
5 Mathematical ability Time outOn a scale of one to ten, rate your
mathematical ability. Find a good source
(online or paper) of drug calculation practice
questions to assess your calculation skills.
CANCER NURSING PRACTICE February 2015 | Volume 14 | Number 1 35
Preventing confusion
Confusion relating to poor prescriber handwriting on
medication charts can lead to administration and
pharmacy errors (Mayo and Duncan 2004, Fry and
Dacey 2007, Ulanimo et al 2007). The Care Quality
Commission has expressed concern about the illegibility
of doctors’ handwriting, stating that staff find some
handwriting difficult to decipher, posing a high risk to
patient safety (Evenstad 2014).
Several studies in hospitals have shown that medication
error rates are substantially reduced with computer order
entry programs – the process of entering medication or
physician orders electronically instead of on paper charts
(Potts et al 2004, Holdsworth et al 2007, Radley et al
2013). While using computer-based systems may not
be possible in all institutions, it remains incumbent on
prescribers to ensure their prescriptions are legible and on
nurses not to administer medication from an illegible or
confusing chart. Similarly, by ensuring medication charts
are clearly legible, and performing adequate checks, errors
resulting from confusion relating to similar drug names and
packages, as well as the misinterpretation of abbreviations,
letters and numerals, may be prevented (Lassetter and
Warnick 2003, Mayo and Duncan 2004, Fry and Dacey
2007, Ulanimo et al 2007).
Now do time out 6.
Conclusion
Medication errors result from a combination of factors
that often appear trivial or insignificant in isolation, but
when compounded may lead to adverse events.
To improve nurses’ knowledge of how individual factors
6 Institutional practices Time outRead the scenario described in the case study
above. Outline what steps Paige should take
to ensure her patients receive the required
intravenous medication correctly. Describe
some institutional practices that could help
prevent medication errors in the scenario.
contribute to errors and help them develop effective
strategies to prevent errors occurring, it is important
that institutions reward and encourage leaders who
demonstrate characteristics of mindfulness on all levels.
A safe reporting environment that encourages staff
engagement to identify contributory factors as well as
possible solutions must also be fostered. Extensive
organisational resources are required to enhance
communication, to reduce confusion, to improve
knowledge, skill and compliance with policies, guidelines
and standards, and to ensure that staff members are
less pressurised. Nurses and other healthcare providers
can contribute individually to patient safety by accessing
available resources that will improve their awareness
and knowledge of medication errors, encourage them to
engage in effective communication with one another and
their patients, and foster a safe reporting environment that
will enable all staff to learn from safety incidents if and
when they occur.
Now do time out 7.
7 Reflective account Time outNow that you have completed the article,
you might like to write a reflective account.
Guidelines to help you are on page 37.
Case study
Paige is a newly qualified nurse who has been seconded to a surgical ward
that is short staffed. When reviewing patients’ charts, she realises that
there are a number of intravenous (IV) antibiotic infusions to administer.
She is unfamiliar with the operation of the IV pumps used on the ward so
she tries to find someone who can show her how they are set. Everyone
seems occupied, but she eventually finds a registered nurse who is willing
to help her. The nurse hands her a manual and, then, in a rushed manner,
briefly explains how the pump is operated. Paige is still unsure about how
the pump is set, but the nurse just suggests that Paige just reads the manual.
Alvarez G, Coiera E (2005) Interruptive
communication patterns in the intensive care
unit ward round. International Journal of
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Aronson J (2009) Medication errors: definitions
and classification. British Journal of Clinical
Pharmacology. 67, 6, 599-604.
Aspden P, Wolcott J, Bootman J et al (Eds)
(2006) Preventing Medication Errors. First edition.
The National Academies Press, Washington DC.
Barger LK, Lockley SW, Rajaratnam SM et al
(2009) Neurobehavioural, health, and safety
consequences associated with shift work in
safety-sensitive professions. Current Neurology
and Neuroscience Reports. 9, 2, 155-164.
Barker K, Flynn E, Pepper G (2002) Observation
method of detecting medication errors.
American Journal of Health-System Pharmacy.
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36 February 2015 | Volume 14 | Number 1 CANCER NURSING PRACTICE
Continuing professional development
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