Medication Errors in Nursing
Introduction
Healthcare professionals are periodically called upon to execute medical orders as part of patient care and the healing process. Besides acting as a key aspect of nursing performance, the execution of medical orders further plays a crucial role in ensuring patient safety (Cheragli et al., 2012; Stratton et al., 2004). According to Hashemi (2007), medication errors could have a considerable impact on the patient’s treatment costs and safety, not to mention possible adverse outcomes like an increased hospital stay, increased medical expenses, and increased mortality (Johnstone and Kanitsaki, 2006). Studies reveal that medication errors account for nearly a third of all medicinal complications (Hashemi, 2007). It is important therefore to have a sound understanding of the various types of medication errors, their causes, prevention strategies, and patient safety issues that surrounds them.
Definition
National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines medication errors as “any preventable event that may cause or lead to an inappropriate medication that may cause or lead to an inappropriate medication use or patient harm while in the control of the health care professional, patient or consumer’’ (2017). Medication errors could be related to healthcare products, professional practices, systems, and procedures. Despite different factors contributing to medical errors, nurses are the most confronted providers in the event of a medical error because they provide hands-on patient care (Lewis, Baernholdt, & Hamric, 2013).
Medication Errors and Patient Safety
Likic and Maxwell (2009) report that medication errors are a real danger to patient safety. Each year, in both England and Wales, the National Health Service (NHS) reports more than 50,000 incidents of medication errors to the UK National Patient Safety Agency (National Patient Safety Agency, 2009). Various factors play a role in the causation of medication errors, with common examples being administration errors, faulty supply, and labelling. Nonetheless, poor prescribing is by far the most cited avoidable medication error, responsible for more than 50% of all preventable medication errors within the hospital care setting (Bates et al., 1995). The majority of the serious medication errors reported within the hospital care setting were dosage errors, of which the majority of such incidents involve junior doctors (Dean, Schatcher, Vincent, & Nick, 2002). Accordingly, junior doctors fresh from medical school are a key target when it comes to interventions aimed at improving patient safety in as far as medication errors are concerned. Specifically, Dean and colleagues (2002) proposed training of junior doctors in the principles of drug dosing prior to starting prescribing drugs as a strategy to minimize dosage errors. In addition, hospitals need to develop cultures, which prioritize prescription writing and formally review the prescriptions that pharmacists make, locum arrangements, and the amount of work designated to junior doctors. Notably, hospitals should sensitize physicians to circumstances in which risks of making such errors are high (Dean et al., 2002).
Types of Medication Errors
While there are various types of medication errors that affect nursing practice, the three most common errors include omission errors, unauthorized errors, and improper dose errors. Omission errors are those that relate to the failure of a nurse to administer a given medication as prescribed. Unauthorised drug errors are those that involve administering or dispensing a different medication from the one the prescriber had authorized. Unauthorised drug errors are attributed to various causes (Bohand et al., 2009). For example, it could result in a case a health care practitioner administers a medication meant for a certain patient to a different patient by mistake. In other cases, a nurse may decide to give medication to a patient without first having been authorized by the physician, constituting unauthorised drug error (Porché (2008). Refilling a prescription by a nurse when there are no more refills remaining and the nurse fails to alert the physician for authorisation also constitutes another cause of unauthorized drug error. Should the nurse proceed to administer medication to a patient based on definite patient parameters, this qualifies as yet another cause of unauthorised error, as does the practice of administering medication without adhering to the set guidelines. In a prospective study conducted by Bohand et al. (2009), omission error and improper dose error were the most frequent forms of medication errors, reported as 30.2% and 31.8%, respectively, of the sample population (Bohand et al., 2009).
Improper dose errors, on the other hand, are those errors that involve administering medication whose strength, quantity, or dose is different from the one prescribed. According to Porché (2008), improper dose error entails administering a prescribed drug to a patient at a dose that is either less than or more than the dosage that the prescriber had ordered. Alternatively, improper dose errors could also entail administering more doses to the patient than what had been prescribed.
Cohen (2007) illustrated the strategy that health professionals could adapt to prevent medication errors. According to Cohen (2007), hospitals should define settings in which pharmacists are not to dispense specific antineoplastic drugs without more expert review. Examples of such situations are such as when “a prescribed dose exceeds a preset maximum single dose, dose per cycle, or cumulative dose” (Cohen, 2007, p. 450). In such situations, Cohen (2007) recommends pharmacists collaborate with physicians, nurses, and other practitioners to determine dosage limits and to institute a review process including other individuals besides the receiving pharmacists and prescribers, to be finished prior to dispensing a drug that exceeds a pre-established limit. This recommendation corresponds to a report from the American Society for Blood and Marrow Transplantation that 15 out of 115 sample transplant centers committed errors constituting a total of 18 patients who received an overdose of chemotherapy from 1989 to 1994. Thirty percent of the incidences constituted improper dose error. According to Naylor (2002), drug-related errors are usually experienced in the form of the wrong route, wrong doses, wrong technique, wrong drug-drug interactions, and wrong frequency. Lack of information or knowledge is by far, "the most important single cause of errors" (Naylor, 2002, p. 79).
The considerable increase in the number of reported incidents of medication errors within the NHS is a clear indication that the NHS has not only improved its reporting culture but is also willing to acknowledge mistakes once they have occurred (National Patient Safety Agency, 2009). The findings of a report by the National Patient Safety Agency titled, 'Safety in doses' that sought to analyse some 72,482 incidents of medication revealed that prescribing errors accounted for 32 percent of the incidents, while medicine administration accounted for 41 percent of the incidents (National Patient Safety Agency, 2009).
Acknowledging and Reporting Medication Errors
It is important to have in place strategies that facilitate error reporting through the use of effective system-level approaches. These are aimed at minimising medication errors. To ensure effectiveness, there is a need to ensure that medication error reporting remains a continuous element of the quality improvement process (Carlton and Blegen, 2006). Past studies reveal that voluntary reporting of medication errors by nurses leads to a 10 to 25 percent reduction in the medication errors reported (Force et al., 2006). Some of the main barriers to reporting medication errors include: (i) Lack of proper definition of what constitutes reportable errors due to a hierarchical hospital structure/culture; (ii) Fear of how the hospital administrators/management will react or respond to a reported error; and (iii) the effort and time taken to report and document an error (Hughes & Blegen, 2008).
Categorization of Medication Errors
Aaronson (2009) notes that the best way to understand better the way medication errors occur, and the most viable strategies for preventing their occurrence is by taking into account the classification. In this case, Aaronson (2009) indicates that medication errors can be modal, psychological, or contextual. Modal errors deal with the manner in which errors occur. For example, by repetition, substitution, or omission, while contextual categorization of errors is concerned with the place, people, time, and medicines involved. The most preferred categorization of medication errors is one that relies on psychological theory (Runciman, Sellen, Webb, Williamson, Currie, Morgan & Russell, 1993) given that it seeks to give explanations as to the causes, as opposed to just describing them.
One of the key benefits of psychological classification of medication errors is that it dwells more on humans as opposed to systems sources of errors Talbot and Aronson (2011). Psychological classification entails four diverse types of medication errors, namely, knowledge-based errors, action-based errors, rule-based errors, and memory-based errors.
Knowledge-based errors occur due to a lack of knowledge regarding medication. For example, the nurse could administer a sulphur-based drug to a patient without having established first if the patient in question is allergic to that compound. Knowledge-based errors during the administration of medication could also occur owing to communication problems between nurses and senior staff, as well as due to challenges encountered in accessing suitable information on drug dosage (Hughes & Blegen, 2008). The best way for the nurse practitioner to avoid knowledge-based errors is via education. In this case, it is important that the nurse or any other prescribing professionals be well-informed about the drug that has been prescribed. Also, the nurse should get to know the patient to whom the drug has been prescribed, including possible allergies they may be suffering from. In the case of student nurses, it is important that they are taught the fundamental principles of therapeutics prior to their qualification as prescribers. Moreover, students ought to undertake tests on the practical application of therapeutics. Knowledge-based medication errors can be intercepted through the use of cross-checking by other staff's computerised prescribing systems, as well as the use of bar-coded systems of medication.
Action-based errors of medication, also known as slips, happen due to the actions of the healthcare professional administering medication picking up a bottle containing a different medication from the one prescribed. This could be a result of slips in attention among the nurse owing to working long hours and work overload. These slips up can happen when prescribing medication, while dispensing, or even during the actual dispensing of the drugs. One way of reducing action-based errors is through the way of creating conditions that make it hard for the errors. This can be achieved by avoiding distractions, ensuring that the nurses are not overworked or overloaded, ensuring that medication is properly labelled (for example, the use of bar codes as identifiers), and by staff cross-checking.
Rule-based errors are those that happen when a good rule has been misapplied, or after a bad rule has been used. For instance, the best route to inject diclofenac is the buttock, but the nurse could instead inject it into the lateral thigh (Cohen, 2007). The best strategy to avoid committing rule-based errors is through the education of staff and having in place proper rules to guide practices.
Memory-based errors are the types of errors that relate to the ability to recall information; thus, they are also referred to as lapses. For instance, a nurse could be aware that the patient is allergic to sulphurs but the nurse forgets the allergy information and ends up administering this compound to the patient anyway (Hughes & Blegen, 2008). It is very hard to overcome memory-based errors. However, one way of intercepting them is by installing systems that aid in their detection, thereby permitting radial measures. Examples include the use of checklists and computerised prescribing systems. Cross-checking could also be helpful.
Conclusion
Nurses occupy the central position in the execution of medical errors, as such, they are directly involved in most medical errors that occur in a healthcare setting. Classifying medical errors empower nurses in making decisions to avoid medical error incidents. To this end, nurses need comprehensive training on medical errors as soon as they are recruited in a healthcare facility to train them about various causes of medical errors, and strategies to avoid them. At the same time, doctors including juniors ought to be informed about the role they play in medication errors and their prevention as pharmacists. The most common medication errors are improper dose errors and require sufficient review of prescriptions between physicians, pharmacists, nurses, and other providers to minimize the incidence of such errors.
References
Aronson, J. K. (2009). Medication errors: definitions and classification. Br J Clin Pharmacol. 67(6), 599–604.
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, Vandser Vliet M, Nemeskal R, Leape LL, 1995, Incidence of adverse drug events and potential adverse drug events: implications for prevention. ADE Prevention Study Group. JAMA, 274, 29–34.
Bohand, X.; Laurent Simon; Eric Perrier; Hélène Mullot; Leslie Lefeuvre; Christian Plotton. 2009. Frequency, types, and potential clinical significance of medication-dispensing errors.
Carlton, G. & Blegen, M.A. (2006). Medication-related errors: a literature review of incidence and antecedents. Annu Rev Nurs Res. 24, 19–38.
Cheraghi, M.A., Nikbakhat Nasabadi, A.R., Mohammad Nejad, E., Salari, A. & Ehsani Kouhi Kheyli, S.R.(2012). Medication Errors Among Nurses in Intensive Care Unites (ICU). J Mazandaran Univ Med Sci., 22(Suppl 1):115-9.
Cohen, M. R. (2007). Medication Errors. Washington, D.C.: American Pharmacist Association.
Dean B, Schachter M, Vincent C, Barber N, 2011, Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care,11:340–4.
Force, M.V., Deering, L. & Hubbe J. (2006). Effective strategies to increase reporting of medication errors in hospitals. J Nurs Admin.,36, 34–41.
Hashemi, F. (2007). Response ethics to nursing errors. J Med Ethic Hist., 4, 31-46.
Hughes, R. G., & Blegen, M. A. (2008). Chapter . In A. f. Quality, Patient safety and quality: An evidence-based handbook for nurses (pp. 397-457).
Johnstone MJ and Kanitsaki, O. (2006). The ethics and practical importance of defining, Distinguishing and discloring errors: A discussion paper. Int J Nurs Stud., 43, 367-76.
Lewis, E. J., Baernholdt, M. & Hamric, A. B. (2013). Nurses’ experience of medical errors: an integrative literature review. Journal of Nursing Care Quality, 28 (2), 153-161.
Likic, R. & Maxwell, S. R. (2009). Prevention of medication errors: teaching and training. Br J Clin Pharmacol, 67(6), 656–661.
Porché, R. A. (2008). Medication Use: A Systems Approach to Reducing Errors. Joint Commission Resources.
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) 2017, Consumer Information for Safe Medication Use. [Online].
National Patient Safety Agency, 2009, Tackling medication incidents and increasing patient safety.
Naylor, R., 2002. Medication Errors: Lessons for Education and Healthcare. Radcliffe Publishing.
Runciman, W. B., Sellen, A., Webb, R. K., Williamson, J. A., Currie, M., Morgan, C., et al. (1993). The Australian incident monitoring study: Errors, incidents and accidents in anaesthetic practice. Anesth Intensive Care , 21, 506-19.
Stratton, K.M, Blegen, M.A., Pepper, G. & Vaughn, T. (2004). Reporting of medication errors by pediatric nurses. J Pediatr Nurs. 19, 385–92.
Talbot, J. & Aronson, J. K. (2011). Stephens' Detection and Evaluation of Adverse Drug Reactions: Principles and Practice. John Wiley & Sons.
