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Medicines management

Reducing nurse medicine administration errors

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Drug administration errors by nurses are a common cause of patient harm. Simple steps can be taken to cut distractions and improve nurses’ skills in calculating doses

Abstract

Errors in administering medicines are common and can compromise the safety of patients. This review discusses the causes of drug administration error in hospitals by student and registered nurses, and the practical measures educators and hospitals can take to improve nurses’ knowledge and skills in medicines management, and reduce drug errors.

Citation: Ofusu R, Jarrett P (2015) Reducing nurse medicine administration errors. Nursing Times; 111: 20, 12-14.

Authors: Rose Ofosu is registered nurse, renal unit, St Helier Hospital; Patricia Jarrett is research fellow, School of Health and Education, Middlesex University.

Introduction

Medication errors are one of the most common causes of harm to patients: up to 6.5% of patients admitted to hospitals are affected. In addition to the human suffering involved, the annual cost related to the adverse effects of medication to inpatients has been estimated as £774m (National Patient Safety Agency, 2007).

A key aim of nursing is to ensure patient safety and at the very least do the patient no harm (Smith, 2005). However, patients are often harmed unnecessarily through drug errors by medical and nursing staff (Cleary-Holdforth and Leufer, 2013). In drug administration, the nurse is the last person in the process to rectify and defend against errors, and needs to know the effect, rationale and compatibilities of the drug, and be able to calculate the correct dose for patients (Rainboth and DeMasi, 2006).

Almost all patients admitted to a clinical setting receive medication as part of their treatment (Esi Owusu Agyemang and While, 2010). Most medication errors occur at the time of administration (Miller and Emanuel, 2010). Many are caused by inadequate prescribing, dispensing, updating of prescriptions and administering of drugs (Royal Pharmaceutical Society, 2009).

There is no specific definition of drug error, as it often depends on the type or classification of mistake (O’Shea, 1999). This can cause confusion and prevent reporting of mistakes and near misses.

Aronson (2009) suggested: “Medication error is failure in drug treatment process that leads to or has the potential to harm the patient.” Many studies use this definition, often in tandem with Franklin et al’s (2005): “Any error in prescribing, dispensing or administering medication”.

Causes of drug errors

The literature identifies four main causes of drug errors by nurses (Table 1, attached).

Interruptions and distractions

Distractions and interruptions are a regular part of nurses’ working lives. If these occur when nurses are preparing and administering medicines, they can lead to drug errors that compromise patient safety.

Kreckler et al (2008) observed 38 medication administration rounds by nurses over a five-week period. They noted that interruptions and distractions were common, and included interruptions by patients, phone calls to the ward, nurses looking for equipment and medications, and further interruptions by other nurses and members of the multidisciplinary team.

Fry and Dacey (2007) designed a questionnaire to investigate nurses’ own perceptions of the causes of medication errors, and whether experience, work environment and seniority affect incidence. They questioned 244 registered nurses from 15 hospital disciplines, including surgical and medical wards, high dependency units, care of the elderly, rehabilitation units, and assessment and observation wards. They found that nurses believe distractions contribute to medication errors on drug rounds. Other factors were illegible handwriting by medical staff and changes in manufacturer packaging of medicines.

In a third study using non-participant observation and semi-structured interviews Dougherty et al (2011) explored the decision-making processes of nurses in a specialist cancer hospital when preparing intravenous continuous and bolus intravenous drug therapy. They observed 20 nurses in two wards over one week, and asked them about their procedure and the potential for drug errors. Interruption and distraction during the preparation of drug therapy was highlighted as a main potential cause of error.

Poor drug calculation skills

Nurses’ numeracy is known to be deficient compared with their other nursing skills (Wright, 2006), despite this being a key nursing competency (NMC, 2008). Poor numeracy has been highlighted as a contributor to medication errors in hospital and the community (Warburton, 2010).

In a UK-based study the drug calculation and numeracy skills of student nurses and registered nurses were correlated with age, status and experience (McMullan et al, 2010). Using a cross-sectional design, 44 registered nurses and 229 second-year diploma student nurses were asked to complete tests in drug calculation and numeracy.

Worryingly, most student nurses and registered nurses failed the drug calculation test (92% and 89% respectively), while half of both groups failed numeracy tests.

Both groups were less able to calculate drips and infusion rates than solids, oral liquids and injections. The authors suggest drug percentage and infusion rate calculations may be conceptually more complicated than other drug calculations and this may explain poor test performance.

Other explanations might be the increased use of technology - for example, intravenous pumps with electronic drip-rate counters may contribute to the loss of nurses skills. Additionally, nurses in primary care settings may not perform infusion rate calculations and so do not routinely use these skills (McMullan et al, 2010).

Wright (2006) showed student nurses found it challenging to interpret and calculate information involving multiplication of fractions. Their level of ability was associated with their education, confidence, and interest in maths and how much they had enjoyed it at school.

A third study assessed the drug calculation skills of 124 registered nurses in five teaching hospitals in the Republic of Ireland. Participants were given a drug calculation test and questionnaire about their drug calculation education. These were used to evaluate their numeracy skills and cognitive processes in calculating drug dosage and rates (Fleming and Brady, 2014).

Overall, 60% of nurses passed the drug calculation test, and only four achieved the top score. As McMullan et al (2010) found, errors seemed to relate to a lack of conceptual understanding, rather than mathematical mistakes. Many nurses had difficulty calculating intravenous infusion drip rates. Fewer than 7% had sat any formal exam on drug calculation in their undergraduate education. The researchers recommended mathematical and conceptual drug calculation skills become a competency in the nursing curriculum.

Inadequate education and compliance

Poor adherence to medicines policy and lack of compliance with prescriptions ordered by the medical team, particularly for dependent and vulnerable patients, may also contribute to medication errors.

Kelly and Wright (2011) assessed the severity of drug administration errors in nurses caring for older patients, observing 62 nurses administering medicines to 625 patients in a stroke unit and a care of older people ward. The rate and severity of medicine administration errors was higher than in studies of patients in care homes or general medical and surgical wards. The most common errors were late or early administration of drugs or drug omission.

These errors were a particular problem for some patients - for example, those with Parkinson’s disease, who need medication on time. A main reason for late administration or omission of drugs was the extra time needed for “difficult” patients. Another factor was nurses leaving drugs on bedside tables to administer to later, which often failed to happen.

Another study by Kelly et al (2011) found higher rates of medication errors for patients with dysphagia compared with those who had no swallowing difficulties. Errors included nurses using the wrong formula and the incorrect preparation of medicines.

Discussion

Drug administration error by nursing staff is a problem in the UK and contributes greatly to patient morbidity and mortality (Wright, 2013). We have identified four factors in drug errors by nurses in hospitals in the UK and Ireland (Table 1).

Nurses work in complex clinical environments that are usually busy, noisy, prone to distraction and interruption, and which often require them to multi-task. Biron et al (2009) reviewed sources, characteristics and rate of work interruptions that might contribute to medication administration errors. From 23 research articles they found other nurses in face-to-face interactions of short duration to be the most frequent source of interruption.

However, Byron et al (2009) criticised the articles for failing to define “interruption”. Other methodological issues were inadequate sample size and lack of representativeness. These reviewers suggest there is limited evidence on the contribution interruptions make to medical administration errors. Other studies highlight interruptions and distractions that reduce nurses’ concentration during drug rounds (Cleary-Holdforth and Leufer, 2013).

Suggestions have been made on how to reduce nursing medication errors (Choo et al 2014). Bennett et al (2010) advocate interventions such as protocol checklists, clothing for nurses with slogans advising not to disturb as administration of medicines are in progress and signage to reduce or limit talking during drug rounds.

Insufficient knowledge and lack of pharmacology education among nurses is another factor. One way to reduce errors might be for each clinical area to have an established and structured preceptorship programme in medicines administration to support nurses who are newly qualified or less experienced in drug administration.

Student nurses have identified that they were not adequately prepared to administer and manage medications safely through their education (Vaismoradi et al, 2014). The transition of the newly qualified nurse from novice to expert could be supervised under the guidance of an experienced nurse or practitioner (Fowler, 2011).

Each clinical practice area should also give new and experienced nurses protected time to improve their learning and professional development in drug calculation and administering medicines. This would produce more knowledgeable and confident practitioners, create a safer environment for patients and increase patient and staff satisfaction (Morgan et al, 2012).

Student nurses’ knowledge and competence in medicines management could also be improved by engaging them in the theory and practice of drug administration through objective structured clinical examinations (Hemingway et al, 2011).

Education and professional development for student and registered nurses should be used to improve nurses’ competence in drug calculation, which the literature shows is lacking. Education programmes are essential to fulfil nurses’ professional and legal obligations, and for patient safety (Miller and Emanuel, 2010).

Technology

Technology will play a part in reducing error in the future. Programmable secure cabinets, similar to vending machines, are likely to replace the drug trolley. The software controls access and maintains records of all issues and receipts. The systems can be interfaced to the hospital patient administration and pharmacy information systems to report on costs at patient and procedural level.

For hospitals with electronic prescribing systems, an interface between the electronic prescription and the secure cabinet can create a “closed loop” of medicines administration, which is thought to offer the best chance of eliminating administration error.

Conclusion

Safe practice in medicine administration is crucial, yet errors by nurses are compromising patient care. Errors can happen at different stages of the administration process, and nurses play a key role in checking the medication is correctly prescribed, signed and dated by the prescriber before administration, and that it is administered as prescribed, following the correct protocols.

Nurse educators need to give registered and student nurses the opportunity to maintain and improve their numeracy and drug calculation skills. Work interruptions while nurses calculate and administer medicines are inevitable, but can be reduced. Hospitals and educators can improve nurses’ knowledge and skills in medicines management and reduce errors.

Key points

  • Nurse drug administration errors are a cause of morbidity and mortality
  • Distractions and interruptions during hospital drug rounds can affect concentration, resulting in medication error
  • Conceptual difficulties and poor numeracy skills can cause nurses to calculate dosages wrongly
  • Drug calculation and administration skills should be required competencies in students’ and registered nurses’ education
  • Strategies to minimise interruptions to drug rounds may help reduce errors. 
  • 6 Comments

Readers' comments (6)


  • It's all OK. Nurses have their red plastic drug pinnies now to prevent interruptions

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  • Student nurses need to have intense lessons in arithmetic. Stop calling it mathematics. I'm now retired, went to a secondary school only did arithmetic but got 100% in my drug calculations to allow me to perform iv drugs. You don't need A levels to do arithmetic.

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  • The authors have engaged only very selectively with recent literature evidence regarding the causes of medication errors. For instance, in their discussion, the authors clearly acknowledge the fact that other reviewers have found limited evidence that interruptions cause medication administration errors. Despite this, the authors go on to assert that interruptions are one of the main causes of drug errors.

    A recent detailed investigation of interruptions experienced by nurses actually concluded that, “beliefs about the ill effects of interruptions remain more a product of conjecture than evidence” (Hopkinson & Jennings 2013). Hopkinson and Jennings state that more research is needed, and that it is likely interruptions have both negative and positive consequences. Another recent study found that only certain specific types of interruption increase the risk of error (Cottney & Innes, 2015), but again, it is stated that more research is needed. As for the authors’ recommendation that “Do not disturb” tabards could reduce drug errors, Raban and Westbrook (2014) clearly outline that there is little evidence to show that this approach is effective.

    Whilst the difficulty of engaging with complex, and often contradictory, evidence in a short article must be recognised, the lack of thorough engagement with the academic literature has led the authors to make claims that will only add to the myth-making and confusion surrounding the causes of medication administration errors. For a much more thorough account of the causes of medication errors, readers are advised to seek out Keers et al’s (2013) excellent systematic review; “Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence”.

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  • A red tabard doesn't make you invisible: quite the opposite in my experience.

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  • Statistically, a prescriber directing Wonderstuff Nmg tds 7 days can make a small number of errors but the nurses administering have 21+ opportunities for incidents including error and wrongfully omitting the dose. Comparative discussions should consider the statistical bias that causes.

    We don't measure medicines factors in causes of admission to hospital. That stat. is mis-used.

    Nurses need arithmetical skills. I have taught nurses add/subtract/multiply/divide since 1985. If you can work in a bar or on a market stall you could do sums for drugs. I have met Consultant Microbiologists who can't do IVI Vancomycin concentration and rate sums and Anaesthetists who struggle with mg to % sums. Junior Drs don't do very well either. Nurses are highly anxious about "maths tests"; even some with paediatrics experience, where need for sums is more frequent. That affects their performance in "assessments". Self-Confidence is a big factor. Training and education increases that.

    Nurses should consider giving routine oral drug rounds to Pharmacy Technicians, who have greater drug knowledge, are good with patients and can support information needs towards their adherence. We do that in some prisons and that works. Nurses can get on with their specialist administration techniques and don't get distracted, and can get on with what they do excellently.
    Get your pharmacist colleagues in to help you reduce your medication incidents causes and understand your needs. Nurses can't do everything and it increases medication error risk to try.

    Yes, I am a pharmacist, and have monitored medication incidents (Acute and CHS) and the causative facors for about 20 years.

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  • eileen shepherd


    The authors have provided the following response to Anonymous | 12-May-2015 10:42 am


    Thank you for your comments, which we would now like to address.
    In our review we have suggested that interruption and distraction of nurses during drug administration is one of four main causes of medication administration errors [MAE’s], not the only cause. Our review of the literature suggests three further causes - drug calculation skills, insufficient knowledge of pharmacology and lack of confidence in administering medicines. Your comments neglect to recognise that four main causes of MAE’s were proposed.

    While we acknowledge our reference to a review by Biron et al (2009),which suggests limited evidence to support the contribution interruptions make to MAE’s, we emphasise these are the findings of this author, not our own views and not the findings from our review of the literature. In our review, we have included studies (not included in Biron et al’s work) the findings of which suggest that interruptions do make a significant contribution to MAE’s (Dougherty et al 2011;Kreckler et al 2008; Fry and, Dacey 2007). These include studies which explore the perceptions of nursing staff on the causes of MAE’s.

    While we accept that Raban and Westbrook (2013) suggest more evidence is needed to support the effectiveness of interventions, such as “do not disturb” tabards worn by nurses to reduce MAE’s, these authors have included many interventions in their systematic review, not just lanyards. There is much evidence to support that wearing of tabards does prevent interruptions leading to MAE’s. For example a recent pre and post intervention study by Verweij et al (2014) found “drug tabards” worn by nurses was effective in reducing MAE’s.

    We thank you for your suggestion for further reading. We do recognise the limitations of our work and of covering such a broad research topic reducing medication errors within a restricted review of the literature. We would always encourage those in practice, academia and research to consult the full range of evidence available.

    References

    Biron A et al (2009) Work interruption and their contribution to medication administration errors:an evidence review. Worldview on Evidence-Based Nursing; 6: 2, 70-86.

    Dougherty L et al (2011). Decision-making process used by nurses during intravenous drug preparation and administration. Journal of Advanced Nursing; 68: 6, 1302-1311.

    Fry MM, Dacey C (2007). Factors contributing to incidents in medicine administration. Part 2. British Journal of Nursing; 16: 11, 676-681.

    Kreckler S et al (2008). Interruptions during drug rounds: an observational study. British Journal of Nursing; 17: 21, 1326-1330.

    Ofosu, R and Jarrett, P, (2015) Reducing nurse medicine administration errors. Nursing Times; 111: 20, 12-14.

    Roban, M and Westbrook, J (2013) Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review, BMJ Quality and Safety. 0, 1-8

    Verweij, L et al (2014) Quiet Please! Drug Round Tabards: Are They Effective and Accepted? A Mixed Method Study. Journal of Nursing Scholarship. 46(5) 340-348

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