There has been an on-going concern about the rising cases of medication errors particularly by nurses. Research has revealed that nurses spend 40% of their time administering drugs. Accurate medication administration is an important aspect in patient safety. There is urgent need to improve the medication administration process and nurses and other medical practitioners have a responsibility of being extra vigilant to ensure that errors are reduced.
Additionally the causes of these errors must be understood before an effective system of reducing errors can be identified. Several areas of weakness have been highlighted as well as the various recommendation suggested. This paper asserts that medication errors can be reduced significantly. However this will take the proactive participation of all stakeholders especially the nurses. All cases of error should be reported so that all can learn from the mistakes. A non-punitive culture must be developed to increase medication error reporting by staff. Introduction
Medication error refers to an event that can be prevented which may be the cause of inappropriate medication use or result in adverse effects on the patient when the medication is being administered by a health care profession, patient or consumer. Such events occur in relation to professional practice, health care products, procedures and systems, prescription process, ineffective communication when making drug orders, improper labeling of products, packaging, errors while compounding, errors during dispensation or distribution, drug monitoring and even abuse (Fish J. 2002)
Incidences of error in drug administration have reached an alarming level with over twelve hundred deaths reported by the institute of health care improvement in relation to medication errors in 1998 alone. Additionally, medication errors this figures are undoubtedly an underestimation of the true figure since many mistakes go unreported. Medication errors are both injurious to patients and costly due to the number of drugs that go to waste as a result of being given incorrectly or to the wrong patients.
Safer use of medicine is a key aspect in the governments’ campaign aimed at increasing quality and safety of health care Causes of Medication Errors In order to begin to prevent medication errors from occurring it is useful to first examine the reasons why they occur. The American Journal of Nursing (2005) attempted to highlight the cause of errors in healthcare delivery, in their document ‘Medication Errors: Why They Happen, and How they can be Prevented’. They concluded that human error, rather than causing mistakes, was itself caused by the failure of the systems that are in place to safeguard patients.
This would seem to place responsibility for reducing errors on the management teams within the Hospital setting. However attractive an option it is to shift individual blame, each nurse has a professional responsibility and should certainly consider their role in risk assessment and error prevention (NMC 2004). Group effort to tackle the issue would seem the most sensible and more enlightened recourse, rather than the ‘us and them’ scenario that often dogs employer/ employee relationships (Shaw et al 2005).
Additionally, O’Shea (1999) and Gladstone (1995) highlighted a number of contributing factors for consideration including; nurses’ knowledge of drugs, length of nursing experience and disruptions or distractions in the ward. In a study designed to identify the underlying systems failures contributing to drug errors, Leape et al (1995) discovered that the most common systems failure, accounting for up to 30% of errors, was lack of drug knowledge.
These findings were supported by a Japanese study (Kawamura, 2001, Armitage & Knapman, 2003) that identified poor knowledge as a key factor in intravenous drug errors. It is both impossible and unreasonable to expect the nurse to have a thorough knowledge of every drug, however Trim (2004) states that nurses working in wards are expected to have an in depth knowledge of the most common drugs used on that particular ward. This knowledge base is constantly updated as new drugs appear. Interruptions and distractions are also often cited as a contributory factor to medication errors (Banning, 2005).
Unfortunately, there is little research available on the actual link between distractions and rate of error, and that which is available is conflicting (Manno & Hayes 2006). However, Chatterjee (2004) found that nurses often perceived distractions to be contributing to an increase in errors. Regardless of the availability of research, common sense would dictate that any task involving medication administration should be undertaken with the nurse’s full concentration. Trim (2004) described the ideal environment in which to deliver nursing care as having the least distractions possible with low noise levels.
Such factors are often outside the individual nurse’s control, however the literature does suggest a number of systems approaches to deal with the constant interruptions from other members of the multi-disciplinary team, visitors and patients at times when the nurse needs to concentrate most. There is no doubt that technological innovations have saved and extended the lives of many patients (Christian, Gyves & Manji 2004). But, increasingly, high-tech health care has had negative effects – often unexpected – on the health and quality of life of patients (Preston 2004).
An instructive example is the introduction of a simple piece of technology such as the latex glove (Sctrohecter 2003). The move away from commonsense procedures, such as hand-washing, has contributed to a high incidence of infection in hospitals (Preston 2004). Inappropriate pharmacological intervention, such as the over-prescription of antibiotics, has also contributed to the increase of ‘super’ infections due to the creation of new, resistant strains of bacteria (Polifroni, McNulty & Allchin 2003). Increased pharmacological technology has contributed to an increase in errors in drug dispensing (Scott 2002).
Drug errors occur mainly during ordering and dispensing, which appears to point to practitioner error but has been shown to be caused mainly by faulty systems (Facchinetti N. J et al 1999). Under-reporting is another area where improvements need to be made. Staff should not feel that they might be disciplined for reporting incidents (Fish J. 2002). Ross et al (2000) carried out a longitudinal study of medication errors in a Scottish children’s hospital. It was found that error reporting increased as a result of assurances that action taken would not be aimed at punishing the person reporting or the one who erred.
Fear of reprisal causes many nurses to fail to report incidences when error occurs. Prevention of Nursing Errors Since a significant fraction of medication errors occur due to lack of sufficient information required to make the right prescription decision, Leape L. L (1995) comments that if a nurse recognizes that they have insufficient knowledge about drugs, then the nurse should set individual learning targets to aid their learning, they are both accountable and responsible for their practice. (Bond, C. A. et al (2002) suggest that nurses need to discuss this with a senior colleague and attend a pharmacology course to gain more confidence in drug administration and drug names.
With regards to placement of newly qualified nurses, who are most likely to have problems with drug administration, the weeks of preceptorship should be extended to enhance their learning and confidence. Even though Cohen M. R (1994), argues that distractions should not be blamed for drug errors, nurses need to report this to their manager in order for the situation to be addressed. VanOyen, M. (2006) further suggest that nurses often complained about their work situation but did nothing constructive to alleviate it such as speaking to senior staff, managers and union representatives.
In reality it is very difficult for nurses to have any influence on the issue of distractions that comes from either patients or staff, (Facchinetti N. J et al 1999). Therefore the important question nurses should be asking is how the distractions could be overcome? Pape et al (2005) in a study based on the American hospitals found that focused protocols and teamwork significantly reduced distractions. A method adopted was the use of signage to draw attention to the need for concentration during drug rounds. The idea was introduced into a hospital, where the signs were placed at strategic areas including medication trolleys. At the same time new protocol was introduced to the ward that required nurses to avoid conversation and prevent interruptions during drug administration. The same protocol was copied to other members of the multidisciplinary team in an effort to gain their co-operation in avoiding interruptions.
The introduction of the signs and the protocol had the desired effect, resulting in a substantial drop in the number of interruptions and distractions during drug administration. However the study did not discuss whether this drop in interruptions actually translated into a drop in errors. Selected nursing units were chosen as part of the study because of staff willingness to participate in innovative research, therefore these results can not be translated generally to all areas and all wards as not all staff are willing to change old practice for new innovations.
Airline research has shown that most errors have occurred as a result of a breakdown in teamwork and co-ordination. In response, the airline industry has placed increased emphasis on maintaining teamwork and clear lines of authority, with safety checklists and a policy of no-conversation at take off and landing, which are critical times for the pilot. Pape et al (2005) advise that similar techniques could be employed such as the use of safety checklists when administering medications and the avoidance of interruptions with designated areas for drawing up and calculating drug dosages.
Such areas, known as treatment rooms or clean sluices are a common feature but they are often busy with more than one nurse needing to use them at the same time, and often in groups of two to enable them to adhere to policy by having two person checks for intravenous or controlled medications. Under reporting robs medical practitioners the opportunity to learn from the errors made. In an attempt to overcome the problem of under reporting error incidents, Journal of Nursing Administration, January 2006 recommend adopting an anonymous, long-term reporting of system problems in a non-punitive environment.
The systems problem approach calls for safety initiatives that focus on improving the wider system in which professionals work. Journal of Nursing Administration, January 2006, advocate local action planning as a proactive measure, thus enabling professionals to identify risk factors and find solutions within their daily practice. Obviously research and a debate on this approach would be worthwhile if drug errors are to be reported honestly and immediately by all health professionals.
It has been suggested that there may be technological solutions and that pharmaceutical manufacturers could adapt their products in order to help nursing managers in their quest to lessen drug errors (Bates D. W et al 1995). Innovations such as ready to use pre-filled syringes and infusions, diluents products that can be permanently connected to drug vials during administration, ampoules and vials with flag labels that can be transferred to easily label syringes and infusion bags are some of the steps already taken by drug companies in order to help the nurse to avoid errors and could be introduced more widely (Cousins et al, 2005).
Regulations introduced by the Food and Drug Administration (FDA) require that identifying bar codes be present on all prescription and over the counter medications in order to reduce hospital drug errors (Vickey, L. Weir. 2005). The introduction of the Centralized Intravenous System (CIVAS) has moved a difficult and risk prone aspect of drug administration away from the nurse and into the hands of those best suited for the role, a simple and cost effective, but valuable solution (Cousins et al 2005).
The number of intravenous drugs supplied by the CIVAS service is currently limited and further study is required to investigate the implications of broadening the service to include all intravenous medications, thereby presumably further lowering the risk of error (Cousins 2005). Conclusion Drug errors are costly in terms of increased hospital stay, patient harm, lives lost and are a source of personal anxiety to the professional nurse, with careers possibly ruined as a consequence.
Medication error has to be addressed in order to safeguard the patients’ well being, to increase public trust in the health institutions under the NHS and to reduce the financial loss that result from these errors. This cannot be done without involving the healthcare staff mainly the nurses. To avoid developing complacent and relaxed attitudes towards drug administration, nurses should be prepared to challenge existing working practices through proactive action planning (Hand & Barber 2000). Several areas of weakness have been highlighted as well as the various recommendation suggested.
It is believed that if these are put in place, then it will be a big step towards reducing the incidences of drug errors. Different aspects of the nursing profession as well as their working environment have been the centre of focus for this paper. The main areas included distractions and disruption, the introduction of signage and checklists to limit the number of disruptions, whilst ensuring that nurses followed medication administration protocol proved valuable, cost effective and simple to implement. Another issue is drug knowledge.
It has been suggested that nurses can work in collaboration with other colleagues in cases where they are not sure of the dosage, type or even the timing. Technology has a role to play in reducing errors. Proper and careful use of technology is essential as well as embracing creative and innovative technology that takes trouble out of the process of drug administration especially intravenous drugs. Alongside these there is the problem of under-reporting incidences of drug administration errors. Instead, it is suggested that these incidences be utilized in learning so that they can be avoided in the future.
It is important that the government, the medical professionals together with all other stakeholders join hands in ensuring that measures are put in place that reduces the incidences of drug errors. However, all the practicing nurses need to take personal responsibility of the way they work. Nurses should play their part by being extra careful as they administer drugs. It is important that nurses increase their skills and knowledge by regularly seeking education. The war against drug administration errors is one that we cannot afford to lose.
Therefore all efforts need to be made to tackle the weaknesses that have been highlighted in this paper. Health professionals have to ensure that all the care provided in hospital and in the health service is as safe and reliable as possible.
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