nursing reflective essay on medication error

Nursing Critical Reflection on Medication Error: A Gibbs Reflective Cycle Analysis

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Medication Error

Introduction.

In this essay, the Gibbs’ (1988) reflective cycle will be used as a framework to reflect on medical error clinical issue. The framework consists of six stages, guiding and deepening the reflection process (Bassot, 2016). The six stages are as follows: description, feelings, evaluation, analysis,conclusion, and action plan (Jayatilleke, & Mackie, 2013).

Description

Patient A underwent a mechanical valve replacement operation, requiring him to consume lifelong warfarin, a high alert medication. His medical officer ordered 1mg of warfarin before rounding after reviewing his PT/INR result. After the order was verified by a pharmacist,I proceed to serve it to patient A. After rounding, the consultant wanted to reduce the dose to 0.5mg and concern over medication error is raised. The consultant wanted to know why the warfarin was served before they reviewed the patient and placed the patient on close monitoring.Fortunately, patient A did not develop any complications.

When questioned, I was baffled and at a loss of words. I believed that I had been compliant with the medication administration protocol. However, I was scared and my heart was beating fast. I did not know how to answer to the consultant and was afraid that something bad would happen to the patient. In the end, I was relieved knowing that nothing had happened to the patient.

I made the mistake of not confirming the dose of a high alert medication before serving it to the patient as I was task-focused, wanting to finish my work in time before handing over to the next shift. It was also not appropriate for the medical officer to order a high alert medication requiring maintenance dosing adjustments without rounding and consulting his seniors. This incident serves as a reminder that I should not blindly follow the doctor’s order even if it is verified by the pharmacist. It is also good to note that the patient did not develop any complications.

According to Aronson (2009), it is important to avoid medication error in maintaining a balanced prescription which reduces the chances of an adverse drug reaction and harm to the patient. The harm which is induced by medication errors associated with anticoagulants can be serious or even fatal for the patient (Henriksen, Nielsen, Hellebek, & Poulsen, 2017). Henriksen et al. (2017) also found that clinically, the most crucial phase resulting in harm to the patient would be the prescription phase.

To sum up, I understood that warfarin being a high alert medication should be handled properly. I should have taken time to confirm the medication order with the medical officer if the registrar or consultant has yet to review the patient. It is apparent that what is done could potentially have caused harm to patient A in which luck was with the patient this time and nothing major happened to him. I realized that I should work towards being a critical thinking nurse and not just another pair of hands following the doctor’s order. In the future, if the medical officer orders warfarin for a patient, I will ensure that the order is reviewed by a registrar or consultant before serving it to the patient. I will highlight this incident to my colleagues for them to be diligent, not repeating the same mistake as I did.

In this essay, medication error clinical issue has been highlighted and reflected upon with the use of Gibbs’ (1988) reflective cycle as a framework. When in doubt, confirmation of the prescription should be carried out, especially for high alert medications.

Aronson J. K. (2009). Medication errors: definitions and classification. British journal of clinical pharmacology , 67(6), 599-604. Bassot, B. (2016). The reflective journal (2nd ed.). London: Palgrave. Henriksen, J. N., Nielsen, L. P., Hellebek, A., & Poulsen, B. K. (2017). Medication errors involving anticoagulants: Data from the Danish patient safety database. Pharmacology research & perspectives , 5(3), e00307. Jayatilleke, N., & Mackie, A. (2013). Reflection as part of continuous professional development for public health professionals: A literature review. Journal of Public Health , 35(2), 308-312.

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Article Contents

Medication errors and the ‘automatic pilot mode’, the link between reflection and mindfulness, the potential value of mindful reflective practice in pharmacy practice, conclusions, declarations.

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Is Mindful Reflective Practice the way forward to reduce medication errors?

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Cinzia Pezzolesi, Maisoon Ghaleb, Andrzej Kostrzewski, Soraya Dhillon, Is Mindful Reflective Practice the way forward to reduce medication errors?, International Journal of Pharmacy Practice , Volume 21, Issue 6, December 2013, Pages 413–416, https://doi.org/10.1111/ijpp.12031

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Medication errors can seriously affect patients and healthcare professionals. In over 60% of cases, medication errors are associated with one or more contributory; individual factors including staff being forgetful, stressed, tired or engaged in multiple tasks simultaneously, often alongside being distracted or interrupted. Routinised hospital practice can lead professionals to work in a state of mindlessness, where it is easy to be unaware of how both body and mind are functioning.

Mindfulness, defined as moment-to-moment awareness of the everyday experience, could represent a useful strategy to improve reflection in pharmacy practice. The importance of reflection to reduce diagnostic errors in medicine has been supported in the literature; however, in pharmaceutical care, reflection has also only been discussed to a limited extent. There is expanding evidence on the effectiveness of mindfulness in the treatment of many mental and physical health problems in the general population, as well as its role in enhancing decision making, empathy and reducing burnout or fatigue in medical staff.

Considering the benefits of mindfulness, the authors suggest that healthcare professionals should be encouraged to develop their practice of mindfulness. This would not only be beneficial in relieving stress, increasing attention levels and awareness, but it is believed that the integration of mindfulness and reflective practice in a ‘Mindful Reflective Practice’ could minimise some of the individual factors that lead to medication errors.

Mindfulness Reflective Practice could therefore represent an important element in pre-registration education and continual professional development for pharmacists and other healthcare professionals.

Medication forms an integral part of any healthcare system and people undergo such medical treatment in the hope that it will benefit their health. However, there is increasing recognition that patients may instead be harmed as a result of errors in medicines management. [ 1 , 2 ] Medication errors are one of the most common types of medical error and it is well known worldwide that the consequences of medication errors are considerable, including physical and emotional harm to patients and their families. [ 3–5 ] Medication errors also affect healthcare staff leading to professional–personal humiliation and to emotional trauma of being involved in the adverse outcome. [ 6 ] Nonetheless they generate a significant financial burden to healthcare systems [ 7–9 ]

Across patient safety research, the importance of reducing medication errors has been recognised and solutions have been implemented, however the individual healthcare professionals' behaviour remain an important and unaddressed element of the system. Research on general medical errors shows that 13–25% of them occur due to mistakes and slips of action and lapses of memory, [ 10 ] also, it was found that the ‘error-producing conditions’ of a medication error in over 60% of cases were associated with one or more personal factors including staff being stressed, tired and/or engaged in multiple tasks, and hence being potentially distracted. [ 11 ] Nonetheless, it is possible that most individuals involved in an error are not aware of the error being made, as if they work on ‘automatic pilot mode’. [ 12 ] Automatic pilot mode refers to all those situations in which an action is taken but there is a lack awareness or focus on the current experience. In psychology, this phenomenon is also called involuntary automaticity and includes the skilled action that people develop through repeatedly practising the same activity, for example driving a car. [ 13 ] In pharmacy practice routinised hospital activities such as daily checking of medicine administration records for patients who have been in hospital a long time or dispensing the same narrow therapeutic range medicine on many occasions are examples of activities that could be conducted in automatic pilot mode. Acting in such way can be very functional at times, as it reduces the degree of conscious attention a person needs to pay to sophisticated activities; [ 14 ] however it could also contribute to increasing the incidence of errors. This is because engaging in a partially unconscious behaviour could prevent the pharmacist from recognising that an error is present and therefore preclude an effective management of an error-prone situation. [ 15 ] A typical example could be the task of checking a prescription before dispensing it. As the dispensing process is a skilled-based task, [ 13 ] i.e. a highly practiced task in which pharmacists are very competent, and there is low degree of conscious control exercised; it is not uncommon to fail to identify the mistake in the prescription.

The likely relationship between reflective practice and diagnostic errors in medicine has been reviewed and the authors have suggested that the reasoning processes which include reflective practice would minimise diagnostic errors. [ 16–19 ] The importance of reflection in pharmaceutical care has also been discussed to a limited extent in the literature. [ 20 ]

Although many authors have recognised that reflection is essential for learning, the term ‘reflection’ is very difficult to define. In the context of a form of thinking it has been traced back to Aristotle's discussions of practical judgement and moral action, [ 21 ] while Dewey [ 22 ] defined reflective thinking as a process that tries to resolve doubt. In an analysis of the way professionals undertake their day-to-day practice Schön [ 23 ] identifies two processes called ‘reflection- in -action’ and ‘reflection- on -action’. The distinction between the two processes is that reflection-in-action is directly related to the current action and refers to the ability of professionals to ‘think what they are doing while they are doing it’. The latter process occurs after the completion of the action and refers to an intentional and often documented reflection on a past event.

Mindfulness could be considered a strategy to improve reflection-in-action. Mindfulness has been defined as ‘a way of paying attention in the present moment, intentionally and non-judgmentally’; [ 24 ] it has its origins in the Buddhist tradition but mindfulness practice is not religious or esoteric in nature. Mindfulness is indeed an inherent human capacity and its goal is to maintain moment-to-moment awareness in the everyday experience. Various techniques, classified as formal and informal practice are typically used to focus the mind. Formal practice draws from disciplines such as meditation, yoga and qigong, an ancient Chinese healing art involving controlled breathing and slow movement exercises. Informal practice requires paying sustained attention into daily routines activities, for example, when walking to the train station in the morning, trying to be aware of all the present moment sensations such as the fresh air, the noise of your steps, or of the people around you. Integrating the practice of mindfulness-based techniques to reflective practice in a ‘Mindful Reflective Practice’ could represent an innovative and more holistic way of approaching pharmacy practice.

The practice of mindfulness has been the subject of increased attention and interest in recent years due to the expanding evidence-base demonstrating that it can be an effective aid in the treatment of many mental and physical health problems, as well as generally improving well-being. [ 25 ] Mindfulness meditation has been associated with structural changes in the in the areas of the brain associated with decision-making, attention and awareness in people who regularly practise. [ 26 ] Other neuro-scientific studies have also shown an increase in activation in the left pre-frontal cortex, the area of the brain involved in establishing positive feelings as well as the area that shows the greatest signs of weakness in depressed people in people undertaking mindfulness training. [ 27 ] Further, regular meditation also results in increased brain activity in areas linked to emotion regulation, such as the hippocampus, the orbito-frontal cortex, the thalamus and the inferior temporal lobe. [ 28 ]

Due to its benefits, the practice of mindfulness techniques has been also explored among healthcare professionals. Epstein [ 29 ] suggested that mindfulness should be considered an essential part of doctors' skills and has a significant role in promoting decision making. One study has demonstrated the benefits of having mindfulness-based intervention instructions for doctors as it significantly improves empathy, and reduces mood disturbance, burnout or fatigue. [ 30 ] Also, a recent review from Ludwing and Kabatt-Zinn [ 31 ] analysed the potential role of mindfulness in medicine. The authors concluded that as practitioners use many different sources ofinformation, this leads to a superficial attention or ‘partial attention’ to the detail and in turn can affect the quality of care.

Bringing a ‘mindful component’ to clinical practice could therefore represent a way of improving the quality of patient care. This seems clear, considering that when acting in a state of mindlessness it is easy to be unaware of what both body and mind are doing (automatic pilot mode) and to operate dangerously in an already complex setting. Regular Mindful Reflective Practice will change this habit of mind-wandering, [ 32 ] in particular by increasing the skill of metacognition i.e. ‘the ability of knowing about thinking’. [ 33 ]

Metacognition has active control over the cognitive processes engaged in learning and a range of tasks such as planning, monitoring, evaluating progress are metacognitive in nature. [ 34 ] The benefits of improving metacognition are therefore vital to support a correct process of prescribing, dispensing and monitoring drugs in which pharmacists are typically involved.

Furthermore, these benefits could not just increment the awareness of individual actions but also of the surrounding environment. This will increase the ability of recognising and interpreting the warning signs of the system, hence further reduce the chance from an error happening.

Considering the benefits of mindfulness, the authors suggest that pharmacists should be encouraged to develop their practice of mindfulness by receiving specific training in mindfulness-based techniques to be applied in their everyday clinical activities, either as part of their continual professional development activities or at an earlier stage during their undergraduate education Protected time to refocus the mind should also be allowed in the workplace. This would not only be beneficial in relieving stress, increasing attention levels but it is believed that eventually ‘Mindful Reflective Practice’ could be the way forward to minimise the individual factors that lead to medication errors.

Conflict of interest

The Author(s) declare(s) that they have no conflicts of interest to disclose.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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Home — Essay Samples — Nursing & Health — Nursing — Medication Error Situational Analysis

Medication Error Situational Analysis and Reflection

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Words: 1325 |

Published: Mar 28, 2019

Words: 1325 | Pages: 3 | 7 min read

Table of contents

Analysis of situation using ways of knowing, reflection and conclusion, works cited.

• Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research, 18(3), 228–231.
• Grissinger, M. (2010). Reducing medication errors in nursing practice. American Journal
• Institute for Safe Medication Practices. (2021). Medication errors. https://www.ismp.org/resources/medication-errors
• Lamont, T. G. (2017). Medication errors: Don’t let them happen to you. Nursing Made Incredibly Easy!, 15(6), 18–23.
• National Coordinating Council for Medication Error Reporting and Prevention. (2015). About medication errors. https://www.nccmerp.org/about-medication-errors
• National Council of State Boards of Nursing. (2018). Medication errors.
• Polk, M. M. (1997). Resilience and human response to chronic illness: Literature review. Journal of Advanced Nursing, 26(4), 800–805.
• Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770.
• Zander, B. (2007). Knowing and knowledge in nursing practice. Journal of Advanced Nursing, 60(2), 132–141.
• World Health Organization. (2017). Medication errors: Technical series on safer primary care. https://www.who.int/publications/i/item/9789241511643

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Elliot RA, Camacho E, Jankovic D Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021; 30:(2)96-105 https://doi.org/10.1136/bmjqs-2019-010206

Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://tinyurl.com/7upnytyy (accessed 20 October 2021)

Scobie S, Thomson R. Building a memory: preventing harm, reducing harm and improving patient safety. The first report of the National Reporting and Learning System and the Patient Safety Observatory.London: National Patient Safety Agency; 2005

Medication errors: a positive safety culture is key

Editor in Chief, British Journal of Nursing

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Patient safety is an essential part of nursing care; the ultimate aim is to avert avoidable errors and harm to patients. The Nursing and Midwifery Council's (NMC) (2018) Code requires nurses to put the interests of people using or needing nursing services first.

Elliot et al (2021) estimated that each year in England there are 237 million errors at some point in the medication process; nearly three-quarters of these have little or no potential for harm but 66 million are theoretically clinically significant. Avoidable drug errors are estimated to cost the NHS in the region of £98.5 million a year, taking up 181 626 bed days, as well as contributing to 1708 deaths.

Where there are hospital admissions because of medication errors, these are most likely to involve non-steroidal anti-inflammatory drugs (NSAIDs), anti-platelet drugs, epilepsy treatments, drugs used in the treatment of hypoglycaemia, diuretics, inhaled corticosteroids, cardiac glycosides and beta blockers. Most of the resulting deaths (80%) are caused by gastrointestinal bleeds from NSAIDs, aspirin, or the anticoagulant warfarin. Errors occur at every stage of the medicines management process, but over half (54%) are made at the point of administration. Error rates are lowest in primary care, but because of the sector's size, these account for around 4 in 10. Around 1 in 5 medication errors are made in the hospital setting.

The Department of Health and Social Care (DHSC) commissioned a new system to monitor and prevent medication errors. However, all Medicines Safety Improvement Programme activities are currently being reviewed so as to offer support to the national COVID-19 response.

The appropriate allocation of healthcare resources to reduce medication errors requires an understanding of where it is these errors exist and where they are causing the most problem. It is essential to use the data to make links between errors and patient outcomes to progress understanding and reduce harm. In order to create an environment that best promotes shared learning, professional regulators and leaders in the health and care organisations should encourage the reporting of medication errors.

Attempting to prevent errors from occurring in the first instance, and the creation of a culture that actively encourages continuous learning and reflection is advocated. Employer organisations should provide their staff with support so that they are able to uphold the standards in the NMC Code as an important part of providing the quality and safety expected by those who use services.

The medication process will never be error free, but steps need to be taken to reduce harm and support mechanisms must be in place to assist those making errors ( Scobie and Thompson, 2005 ). People make mistakes all the time, not generally because they are incompetent or callous or negligent, but because of the complex systems in which they work. As there are so many possibilities for things to go wrong it is inappropriate for nurses to be punished when they make mistakes. Developing a culture of safety in an organisation and fostering a proactive approach to patient safety can enable meaningful learning to take place when errors have occurred. Increased incident reporting is a strong positive indicator of a good safety culture. Where there are negative attitudes and behaviours these will discourage staff from learning from preventable incidents. In an environment such as this, it is more likely that such incidents will occur again.

Missed Medication – Reflective Account

NMC Revalidation Reflective Account on Missed Medication

As per the format given by NMC, any reflective account should be written under the four headings. Lets discuss it one by one.

What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?

Missed medication during drug rounds.

What did you learn from the CPD activity and/or feedback and/or event or experience in your practice?

I learnt the importance of checking the drug chart thoroughly including all the pages and medicines given in previous shift as well. I also learned the need for nurses to have thorough knowledge of the medications given to the patient. If you find anything wrong with prescription, it is also important to challenge the prescriber.

How did you change or improve your practice as a result of missed medication?

I made sure that I read all the pages and prescriptions thoroughly before administering medication during medication rounds. Observations are always checkedfor any abnormalities before giving medications. I am now checking of the legibility of prescription and is able to challenge the prescriber if I find anything wrong with the prescription. I make sure that the patient understand the indication of medication and its possible side effects before administering medication. In case the medication can’t be administered in the prescribed route, I will check for any other alternative forms of the same medicine which can be administered to the patient. For e.g. Tab aspirin 300 mg PO has a rectal preparation as well with the same strength. So I can make sure that a critical medicine is not missed in this way.

I am now administering the critical medications on time without any delay. Regularly, i do make a note in handover on any patients who are on critical medications, which removes the chance of missed medications.  Also, i follow the 10 rights of medications while administering medications. I have also improved my knowledge on the common medications administered on my area after this particular incident. If any medications is not administered, I make sure that the correct code is put, nurse in charge is informed and will write the reason for non-administration in notes/drug chart as per hospital policy.

How is this relevant to the Code?

The themes relevant to this code are Practise effectively, Preserve safety, Promote Professionalism and trust.

NHS Pharmacy update on Missed Medication – Click Here

Hopes this article throws light to develop your own reflective account on any experience you choose. Thanks for reading.

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Critical Medication Incident Reflection

Introduction.

Reflection is an essential and necessary skill for all health care professionals and is also in line with (NMBA, 2017). Reflective practice ensures continual learning and enables health practitioners to improve their practice as it encourages self-evaluation (Murdoch, 2019). Reflection also aids in discovering beliefs, values, and information ingrained in experiences (Sorrell, 2017). Gibbs’s reflective cycle has been chosen because it is easy to use. Also, encourages a detailed account of the circumstances, assessment of the feelings and experience, analysis to make sense of the experience, conclusion where other options are taken into consideration, and reflection on the experience to consider what one would do if the circumstance arose again (Ardian, Hariyati, & Afifah, 2019). The incident was a miscommunication incident between nurses that resulted in the patient being given double doses. This incident was selected because it made the nurse aware of his shortcomings and those of other team members, which caused him to dwell on the incident and consider what lessons could be drawn from it to avoid repeating the same error.

Additionally, according to Billstein-Leiber et al. (2018), communication is necessary for nursing practice as it underpins quality healthcare, patient satisfaction, and the realization of favorable health outcomes. As directed by the Gibbs reflective cycle, the incidence will be described briefly; the nurse’s feelings and why the incidence is essential to nursing practice will be discussed. Later an action plan will be formulated to ensure the nurse handles the situation better if it occurs again. Confidentiality is essential to reflection; therefore, the patient will be referred to as (Rose, not her real name).

Description

Rose was a 23-year-old female admitted to the hospital for colorectal surgery. Rose’s prescription included a dose of paracetamol three times a day. As the team leader, I was supposed to oversee other nurses and patient care transitions. Therefore I went through hand-over charts between shifts. As I did the PCA checks and obs at 1701 hrs, I noticed there was an IV paracetamol that was still clamped. I cross-checked the medication chart and realized that the paracetamol IV was ticked at 1638 hours. Since it was only 30 minutes later, I assumed my partner had forgotten to unclamp the IV medication, so I unclamped it. After one hour, I noticed the IV, approached me, and told me that the morning shift nurse had left the IV medication unadministered. Hence, she decided to administer oral paracetamol. This is where I realized that the patient had received a double dose of paracetamol. We decided to recommend that Rose undergoes Liver function tests. Rose’s paracetamol levels were slightly raised, but below the treatment requirement, so we monitored her for a few hours. I also went ahead and changed the administration time and indicated in the charts the drugs administered.

I was anxious and worried about making mistakes when assigned the leadership position. However, I was able to overlook the fear and perform my responsibilities. According to Wondmieneh et al. (2020), those who experience medication errors often experience emotional distress and a lack of confidence. When this incident occurred, I felt discouraged and doubted my clinical skills. I was angry that my partner did not communicate that she administered oral paracetamol but indicated in the chart that it was an IV. I felt disturbed and sad about the double dosage. I feared losing my job and facing litigation due to the error. I feel I dealt with the situation with outward calm and in a professional manner that ensured the patient’s safety. In the end, I was very pleased Rose’s situation did not worsen, and she recovered without further complications.

The experience was good because the patient was not seriously affected by the double dosage error. In addition, because my partner and I communicated immediately after the symptoms were exhibited, we could start a reversal treatment immediately; hence the patient did not develop liver sepsis. However, I worked on the assumption in this situation when I could have asked my partner. If I had asked her, the medication error could have been avoided. The patient experienced side effects because of the double dosage. I failed to adhere to all seven rights (7rs), the right patient, medication, dose, route, time, Response, and documentation (Jones & Treiber, 2018). As a result, the patient was negatively affected. Proper documentation of medication can aid prevent medical errors from occurring within the hospital (Wheeler et al., 2018). However, in this case, there was no proper documentation by the morning shift nurse and my partner, which prevented me from assessing relevant information.

In addition, I did not adhere to the recommended medication adherence practice. Hospital staff must report all incidents they observe or errors they make. Therefore by involving the Chief Medical officer, risk man, and Manager, I was adhering to the policies and regulations of the hospital; hence the case was managed efficiently in line with this, and the LFT levels were checked immediately. This was good because the patient was monitored for any evidence of an adverse reaction.

Medical mistakes are rarely the result of careless or inexperienced medical personnel. Instead, they frequently result from a breakdown in the procedures that control how patient care is delivered (Sorrell, 2017). Medication errors often occur in the administration phase (Wondmieneh et al., 2020). Therefore effective communication is essential in this phase. Teamwork requires cooperation, communication, and coordination between members of a team. My partner and I failed to communicate effectively in the team dynamic in this incident, and hence Rose suffered. Shitu et al. (2018) discovered that effective interdisciplinary communication is a prerequisite for providing high-quality healthcare. Rose’s safety was reduced by ineffective communication between staff. Shitu et al. (2018) further suggest that other medication errors can be avoided through effective communication between the nurse and the patient. Involving the patient in medication management could have prevented the double dosage. Rose could have informed me about the Oral medication she had received from my partner.

According to the (NMBA) (2017), when Registered nurse delegates tasks, they should ensure they supervise the practice to ensure that delegated practice is safe and correct. However, as the leader, I failed to adhere to this direction; I did not supervise the work done by my partner. Morover, Hanson & Haddad. (2021) have argued that nurses should not “blindly” give medications; instead, they should seek clarification when needed. In addition, Rodziewicz et al. (2022) advocate for double-checking before medication administration. I, however, administered Rose’s medication blindly, guided by my assumption rather than confirming facts. I should have double-checked with the patient medication chart to ensure that the correct dose of medication is administered to the patient at the right time (Rodziewicz et al., 2022). This medication error was avoidable if I had gone through the patient medication chart carefully before administering it and communicated with my partner before deciding to administer it. Therefore, it can be said that such situations happen due to a lack of communication and lack of proper documentation concerning patient care.

When I realized the patient had received a double dose of the medication, I immediately informed the Chief Medical officer (CMO). I made this decision because nurses have an ethical obligation to help prevent and manage medical errors (Sorrell, 2017). Therefore by reporting, I was putting the patient’s concerns first and fulfilling my ethical obligation. In many circumstances, however, nurses do not report errors because of fear of litigation (Rodziewicz et al., 2022; Sorrell, 2017; Wondmieneh et al., 2020) ). I was aware that the double dose of the medication posed a substantial threat to patient safety. therefore, by testing the LFT levels, I was also fulfilling my ethical principle of Beneficence and Non-maleficence (Sorrell, 2017) by taking the necessary steps to minimize the harm caused by an error. In line with this, I should have informed Rose of the error. For instance, if the levels were significantly raised and I failed to inform her of the error, she may have refused the additional treatment required to reduce the rising levels.

To avoid this situation, I would double-check the medication chart and communicate with the nurse that was supposed to administer the medication. In addition, I would never administer medication that I have not prepared or helped prepare. If there is any uncertainty over any aspect of medication, I should consult with the nurse in charge and, if need be, the prescribing officer. In other circumstances, I would also consider the patient’s current condition when administering drugs. For instance, Rose was not exhibiting any signs of pain in this circumstance, which should have prompted me to ask my partner about the pain medication instead of directly administering it. It is also essential for a nurse to the rationale for the drug administration. Considering the reason for administration would ensure an overdose or medication error is not made. For instance, in this case, the reason for administration was based on an assumption instead of a viable reason.

Action plan

Miscommunication by different parties was the leading cause of medication error in this incident. Therefore if put in a leadership position, I would organize a safety talk around the facility I am posted to ensure nurses are educated on the importance of double-checking medication and making the correct documentation. Drug administration guidelines ensure that nurses will not repeat the same mistake. The nurses would be educated that medication administration should be clearly and accurately recorded immediately. And if a drug was not administered deliberately, it should also be documented. My partner should have documented the unadministered IV and the administration of the oral paracetamol; hence such a proram would educate her. the program would also encourage sharing Stories of Errors rather than keeping mistakes hidden because of fear and hearing other people’s stories. Other staff members can prevent and/or manage healthcare errors by being aware of how others have handled errors or wish they had managed them differently.

In addition, I will undertake an online leadership course to ensure that I am equipped to create an environment where my team members can collaborate and communicate efficiently. I believe the course will equip me with the skills to respectfully hold others within the team accountable. Additionally, I will be more cautious while dispensing medication in my future practice by carefully checking medication charts. I will always follow the medicine checks, time, and seven rights. In a leadership position, I would also design Checklists, Reminders, and Double Checks to reduce medical errors, especially when errors are likely to occur.

Ardian, P., Hariyati, R. T. S. & Afifah, E., 2019. Correlation between implementation case reflection discussion based on the Graham Gibbs Cycle and nurses’ critical thinking skills. Enfermería Clínica, 29(2), p. 588–593.

Hanson, A. & Haddad., L. M., 2021. Nursing Rights of Medication Administration. StatPearls.

Jones, J. H. & Treiber, L. A., 2018. Nurses’ rights of medication administration: Includingauthority with accountability and responsibility. Nursing Forum, 53(3), p. 299–303.

Murdoch, M., 2019. How to reflect on your practice for revalidation. Nursing in practice.

Nursing and midwifery board Aphra, 2017. Registered nurse standards for practice. [Online] Available at: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Rodziewicz, T. L., Houseman, B. & Hipskind., J. E., 2022. Medical Error Reduction and Prevention. StatPearls [Internet].

Shitu, Z. et al., 2018. Avoiding Medication Errors through Effective Communication in Healthcare Environment. Movement, Health & Exercise, 7(1), pp. 113-126.

Sorrell, J., 2017. “Ethics: Ethical Issues with Medical Errors: Shaping a Culture of Safety in Healthcare .”OJIN: The Online Journal of Issues in Nursing, 22(2).

Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business . Australian Prescriber , 41(3), 73–77. https://doi.org/10.18773/austprescr.2018.021

Wondmieneh, A., Alemu, W., Tadele, N. & Demis, A., 2020. Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing.

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The complexity of clinical nursing practice, chaotic and technical nature of the workplace environment coupled with the multiple and varied roles of nurses, leads to cognitive overload that may overwhelm nurses, which may result in medication errors. All medication errors are considered serious events, but some may consequently be harmful to patients and have a lasting effect on the nurses involved in making the error. This study examined what it was like to make a medication error for registered nurses. A descriptive phenomenological study rooted in the philosophical tradition of Husserl [1] was conducted on eight registered nurses via two in-depth face to face interviews. The data generated from a total of sixteen interviews and field notes were analyzed using Colaizzi’s seven-step method. Five theme categories emerged: Immediate Impact: Psychological and Physical Reactions; Multiple Causes within Chaos: Cognitive Dimensions; Embedded Challenges: Healthcare Setting; Organizational Culture: Within the Place/Within the Person; Dynamics of Reflection: Looking Forward . The lived experience of making a medication administration error led nurses to the realization that a profound occurrence had taken place. As a result, these nurses experienced upheavals that were of a physical and emotional nature, which threatened their professional status and generated a sense of low self-esteem that considerably decreased their selfconfidence. An overwhelming amount of workload, a stressful work environment and mistreatment by peers were predominantly noted as the factors that led to these errors. Nurses in this study offered suggestions to improve the system but felt their concerns were often undervalued. Implications for nursing education and nursing practice, to significantly improve teaching strategies of medication administration process leading to improved patient outcomes, were suggested.

1. Background

2. significance.

Patient safety continues to be a matter of concern for nurses, nurse leaders and administrators. This was first substantiated by the Institute of Medicine (IOM) through their first report released in the year 2000, entitled ‘To Err Is Human: Building a Safer Healthcare System’. Subsequently, over time IOM published multiple reports that underscored that medication errors were the leading and most common predictable cause for adverse events in healthcare facilities, and that administration errors were placed as the most common identifiable medical errors in the USA. This additionally, called attention of healthcare professionals, nurse leaders and nurses to the high rates of negative patient outcomes, some of which were quite harmful to the patients and may have costed them their lives [4 - 8] . Literature reviewed over two decades revealed that medication errors occur frequently in hospitals and may prove to be fatal and costly. A study published in the United States on medical errors, highlighted that out of 48,000-98,000 deaths that were related to drug complications, about 7000 deaths were related to medication errors annually [9] . Another study reported that administration errors account for approximately 59% of all medication errors and one out of every three adverse drug events (ADEs) is related to medication errors. A study conducted in two teaching hospitals revealed that about 2% of patients admitted experienced preventable ADEs, costing the hospital approximately $4,700 per admission or nearly $2.8 million annually for a 700-bedded teaching hospital and if these findings could be generalized then the preventable ADEs are costing the country approximately $2 billion per year. A 1997 study reviewed admissions in a large teaching hospital that indicated 2.43 of the admissions out of 100 admissions were complicated due to an ADE. This led to an increase in the length of stay (LOS) of these patients by 1.91 days escalating the cost to the hospital by $2, 262. Additionally, ADEs indirectly impact costs for loss of productivity, disability and other care related costs [4 , 10 - 13] .

3. The Study

The purpose of this study was to examine and understand the lived experience of nurses’ involvement in making one or more medication errors that reached the patient, may have resulted in negative patient outcomes. This study also attempted to gain a unique understanding of how these nurses coped with the aftermath, as well as to more and fully understand the support nurses may need after the occurrence.

Research questions:

‘What is the lived experience of nurses involved in medication errors?’

‘What is the lived experience of these nurses caring for patients after the medication error occurred?’

‘What is the lived experience of these nurses working on the unit after the medication error occurred?’

3.1 Design and methodology

A qualitative descriptive phenomenology rooted in the philosophical tradition of Husserl was conducted. Two interviews were carried out with each participant and the research data were generated from a total of sixteen interviews and field notes. Colaizzi’s seven-step methodological guidelines were used for analysis and interpretation of data.

3.2 Participant recruitment and profile

Participants for this study were registered nurses (RNs) employed in facilities and experienced in caring for patients in a variety of healthcare areas. These nurses were currently practicing with a valid RN license for at least six months in the state of New York. A purposive sample of eight RNs with the above inclusion criteria who were directly involved in one or more medication errors were selected. The recruitment of participants was primarily done by snowballing method. The first participant however, was recruited by posting a flyer on the announcement board of a RN- BS completion program. The study sample comprised of seven female and one male participant with ages ranging from 36-55 years. The educational background of one participant was associate degree in nursing; five held a baccalaureate degree and two were masters prepared RNs. Their professional experience of practicing as RNs ranged from 3-22 years. Two participants prior to practicing as RNs also had the opportunity to practice as licensed practical nurses (LPNs). Most of the participants had the opportunity to practice in more than one area of expertise. The work areas of these participants were: medicalsurgical, neurology intensive care unit, emergency department, telemetry, intensive care unit, nursing home and home care. Most of the participants were full time registered nurses in one facility with a second part-time job in another facility. Two participants worked as per diem RNs in their second job and floated to a different unit almost every day. Of the eight participants, three participants worked eighthour day shifts, one worked twelve-hour day shift and one worked both day and night eight-hour shifts. The remaining three participants worked twelve-hour night shifts (table 1 below shows participant demographics).

3.3 Data collection

Data collection was done by the principle investigator via two faceto- face interviews. The first interview was an in-depth interview with open-ended questions; the second being a focused interview with probes to clarify information obtained during the first interview. This style of interviewing allowed the researcher to follow the participant’s lead to format clarifying questions for the second interview [14] . The researcher carefully observed participants’ during the interviewing process for any nonverbal expressions and the elements of their environment. The observations were recorded in the field notes. The researcher encouraged each participant to describe his or her lived experience without leading the discussion. Broad open-ended questions were used in the first interview to allow participants to gradually ease into the interviewing process.

Examples of questions included in the first interview were: ‘Describe the incident when you were involved in a medication error’. ‘Describe your feelings when you made the medication error.’ Probes were used in the second interview, examples of these were: ‘What was it like to care for the patient involved in the incident?’ ‘What were the reactions of your colleagues/supervisor after the incident?’ Based on the literature review the interview questions were structured to focus on specific areas like:

• Nurses’ reactions (physical, emotional and psychological) to medication error occurrence immediately after the incident, and later.
• Factors within practice environment that led to medication error occurrences.
• Challenges faced by nurses before during and after medication error occurrence.
• Culture within the work area and /or factors that predisposed to medication error occurrences.
• Coping mechanisms used by nurses when medication error/s occurred.
• Type of support needed by nurses after the medication error occurrence.
• Nurses’ perceptions as to why the medication error occurred.
• Nurses’ reflections about error occurrence and effects on future practice.

Each interview lasted approximately 50-60 minutes. These were conducted in a private area of choice of each participant. The duration of data collection process was about three months. Being that all except the first participant were recruited by snowballing method, the interviews were conducted as participants were recruited. The second interview was scheduled by setting a date approximately one week later immediately after the first interview was completed. The date was scheduled according to the convenience of the participants. All interviews were conducted by the principal investigator and completed as scheduled except participant #3, whose second interview was scheduled after three weeks due to an illness. Even though questions for the two interviews were previously formatted to gain basic information, the researcher (interviewer) reformatted interview questions to make their meanings explicit to respondents as needed.

3.4 Trustworthiness and rigor

Techniques to ensure trustworthiness were employed by engaging participants, member checking, thick descriptions, and audit trail methods for this study. Participant engagement was accomplished by building a relation of trust between the investigator and the participant. The researcher gave relevant explanations and answered any questions the participants had prior to interview, enabling comfort and gradual ease into the interview process. Member checking involved the action of returning of the investigator to each participant after the interview process was complete to ensure correctness of the information given by the participant and to validate the essential structure developed for the preservation of the true meaning of the experiences [15] . The researcher made the participant aware of this at the time of interview sessions. All participants responded via email. Thick descriptions were key to the meaning of research and an important aspect of trustworthiness. The researcher sought permission and verification to use narratives, which was crucial for this study. Finally, audit trail was critical to establishing authenticity and trustworthiness of the data. The researcher documented the research activities over time with clarity and in a systematic way to be followed by others to understand the line of thinking used by researcher at the time of data analysis [16 , 17] . To ensure methodological rigor the researcher used the processes of phenomenological reduction, bracketing and member checking. The researcher’s attitude was non-judgmental, she practiced the art of openness as the data were revealed, which was carried out before the study began and continued throughout data collection and data analysis [14] .

3.5 Ethical considerations

The study was approved by Institutional Review Board, Adelphi University, New York. The researcher obtained a written informed consent from each participant prior to data collection. The participants were assured of confidentiality and the right to withdraw from the study at any time during the research. Anonymity was not completely assured, as the researcher was the interviewer however, the participants’ names were coded to allow for confidentiality when data was examined by experts. Since the study investigated error in the participants’ workplaces, all methods to eliminate and/or avoid coercion were employed always during the research. Permission to tape record the interviews was obtained prior to each interview being conducted. To ensure participant privacy and comfort the interviews were conducted in a private area that allowed for a calm environment [14] . A “cooling-off” period was provided to individual participants before moving the interview forward in case of any emotional upset or distress during the interview process while they reflected upon their experiences of medication errors. Individual participants were also provided the opportunity to reschedule the interview if needed.

3.6 Data analysis

The recorded interviews were transcribed verbatim by the researcher. Transcription of interviews was completed in approximately two months. The data collected from the eight participant’s interviews revealed ten medication errors which were categorized as: unauthorized drug error, wrong route error, wrong dose error, omission error and wrong documentation error (table 2). The interviewer also gathered additional data in the form of field notes for all eight participants. Data were subjected to intense and thorough analysis utilizing Colaizzi’s method, significant statements were extracted and in-depth explanation of the meaning of each statement was achieved after coding the data. This process was valuable in understanding the actual meaning behind each statement made by the participants. Coding and intense analysis of data resulted in two hundred and thirty formulated meanings. All data were coded by hand by the researcher. As the process of coding and recoding continued previously examined codes were re-examined for new codes and repetitions retained for each protocol. The transcripts were reviewed with a doctorally prepared nurse researcher for authenticity and validation of the coding system. Significant statements were subjected to systematic review, formulated meanings were carefully constructed to preserve the context of the protocol as closely as possible to the stated expressions to ensure preservation and significance of their meaning. Formulated meanings were organized into clusters of themes and theme categories. Themes were continuously referred back to the original protocols to ensure validation and commonality of themes.

The data were finally organized into nineteen theme clusters and five theme categories. The findings presented are the nurses’ (participants) descriptions of the reality of their lived experiences of making one or more medication errors. The actuality of the meaning was derived from the experiences that these nurses lived through during and after the medication error ocurred. Following are the descriptions derived from the lived experiences of eight registered nurses and are presented under five theme categories.

4. Theme category 1- Immediate Impact: Psychological and Physical Reactions

Nurses described the immediate reactions of mind and body experienced by them when a medication error was committed. They verbalized feelings of fear, anxiety, remorse, disappointment, unbelief, embarrassment, tearful and being visibly shaken.

“…It was embarrassing and very painful as a human being...I was upset (for the patient) and I was embarrassed (for myself).”

“...I used to cry for everything...it was just like, ‘Oh! My God!! This is the worst thing that could’ve happened to me…!

“...I was so scared! I was so scared!!! Because it’s a blood pressure medication...

Nurses described the experiences to be emotionally draining and physically challenging as they threatened their personal and professional self. This, ultimately culminated into first a fear for the wellbeing of their patient and next a fear of losing their job. Nurses expressed concerns about the lack of collegiality and the environment of animosity that prevailed in workplaces which undermined their self-confidence to the extent that impeded their professional growth.

5. Theme Category 2- Multiple Causes within Chaos: Cognitive Dimensions

Nurses described multiple factors that impacted cognition which resulted in medication error occurrences. They spoke about practice challenges of being a new nurse, working in nursing homes with forty patients to one RN, balancing multiple roles and responsibilities, workplace demands while caring for very sick patients. Nurses were concerned about the lack of support and an atmosphere of unfriendliness specifically experienced as newly hired nurses which made them unsure of themselves because they were expected to perform as experts even though they were novices with lack of support from their senior counterparts. Nurses also verbalized being physically and mentally exhausted with practically no breaks or recess due to the constant busyness and excess work demands.

“...being new to the system...considering the ratio of the patient...I had to give medication to forty patients...at 10 o’clock and there are a lot of them (medications)!”

“... as a new nurse there was time management, bullying, that is just there and then...just trying to learn your trade as well as the real-world side of it... and being so unsure of myself...it could happen to anybody...”

“...and if you have things on your mind, you are sleep deprived, you are tired, you are hungry you’re (nurse) prone to make error...”

6. Theme Category 3 - Embedded Challenges: Healthcare Setting

Nurses expressed concerns about the current healthcare system while describing experiences of constant struggle to meet multiple patient care demands in terms of patient care related situations which stemmed from disparities in work routines which were mostly related to a culture of unsupport prevalent among the leaders and peers and embedded in the work environment.

“...they (peers) start to pick at you and try to find things...it could really be an experience of true learning, but it’s not...you are a nervous wreck … they (peers) are like questioning this and that and trying to get you in trouble…”

7. Theme Category 4- Organizational Culture: Within the Place, Within the Person

Nurses described their experiences of an organizational climate that was mostly unaccepting and unsupportive of newcomers and was commonly rooted within the workplace and reflective of the behaviors of the nursing colleagues and leaders. Participants described experiences where they were afraid to approach senior colleagues for assistance or to voice concerns regarding patient care due to lack of camaraderie, support and collegiality.

“I remember being extremely tired, ...you are new, they’re (co-workers) looking for any reason to get you in trouble...Well it was definitely always lack of support… they didn’t want me there to begin with… a new grad, out of, out of... school! so of course they start to pick at you and try to find things…

“...a harsh scolding at the front desk, early in the morning...is highly inappropriate and should not have been done in that forum... this nurse already feels terrible, she is supposed to go home and this is what she goes home from...”

“It’s all very, very stressful for a nurse! …because she gives the medications, she or he, so it’s ultimately that nurse’s FAULT if there is an error made you know, it’s very unfortunate!... they just have to put better practices in place…better staffing where they are supportive staff, not staff that are ‘bullies’... They (nurses) don’t need to be in an environment and be ridiculed!”

8. Theme Category 5-Dynamics of Reflection: Looking Forward

Nurses reflected upon experiences and identified multiple issues linked to the ever-changing dynamics of the healthcare system and the negative outcomes in terms of patient care and safety and its unfavorable impact on nurses professionally. Nurses described experiences that were linked to the contemporary organizational structure embedded in the healthcare facilities and expressed feelings of being treated unjustly by the leaders most of the times and not being heard in terms of factors that led to the medication error incidents. Nurses strongly expressed concerns about being held responsible for medication errors without being able to voice concerns and felt that such behaviors of organizational leaders will not serve to resolve issues and errors will constantly occur and nurses will continue to leave. Nurses also expressed strong concerns about unreceptiveness of organizational leaders to suggestions of relevant changes to the current healthcare system for improvement of future practice. Finally, nurses identified ways of fostering positive changes and just culture in the workplace environment to improve systems in healthcare facilities.

“…a lot of people...don’t stay when they see the overload of work and the demand on the floor especially on a medical-surgical unit...”

“...Patient load hasn’t really gotten better ...I moved from that 10:1, I thought that was too much! Spent three years in med-surg... There is a lot to do, just a lot to do! It’s very you know demanding kind of work...”

“...incident reporting is not necessarily a bad thing but it’s usually a reactionary thing in terms of med errors...to make it a proactive measure... a way to improve patient care or just put a positive spin on it... it’s called an ‘incident report’! ...it could also be… ‘caution report’ or something...just detaching the behavior from a person... that’s what makes it a positive thing”.

9. Discussion of Findings

Following is the discussion presented based on the findings of this study. The findings obtained were compared to the previous studies on medication errors and then the findings from this study were highlighted. The new findings that emerged from this study, although bear some similarities to findings of previous studies are unique in the way they were expressed by the participants of this study.

9.1 Fear and anxiety, self-degradation

Nurses verbalized feelings of extreme emotional and physical nature which resulted from situations after the medication error was committed. Nurses feared for the patient’s wellbeing, but were equally anxious and fearful about being reprimanded, losing their job or professional license. Nurses also expressed thoughts of selfdegradation and remorse with respect to medication error occurrences and blamed themselves for the incidents. These feelings were similar to those expressed by nurses in other related studies [2 , 3 , 18] .

“I was speechless…I really didn’t know what to do!”

“I feel like I failed my patient that day…”

Nurses, however, also spoke about multiple factors that contributed to these medication errors, particularly, the chaotic demands of the workplace with little or no organizational support. They said that if certain common issues were anticipated and addressed, the medication error/s could have been prevented.

9.2 Being overwhelmed and coping, being a new nurse and facing practice challenges

This study illuminated nurses’ experiences of situations highlighting the complexity of workplace which was exceptionally distressing and overwhelming for nurses as they cared for patients while simultaneously trying to cope with difficult situations. Nurses expressed feelings of frustration and inadequacy when they were unable to complete patient related tasks and were constantly struggling to balance multiple RN responsibilities of patient care along with administering medications.

...when I was in med-surg for three years; it was so stressful…so overwhelming! … you’re dealing with different diagnoses, different treatment plans …antibiotics every 6 hours… you have to draw blood, monitor vital signs… monitor a seizure … patient with infected peg…changing dressings…it’s just heavy task!”

Participants also stated that such experiences were mostly challenging when they were novices striving to familiarize themselves with the intricacies of the profession and simultaneously caring for patients of diverse nature. Nurses spoke about encountering stressful situations with colleagues and nurse leaders and experienced mistreatment and lack of guidance. Previous studies identified similar situations and experiences of nurses that reported inefficiencies, distractions, multiple factors and latent failures significant to error incidents [19 - 21] .

Nurses spoke about altering their own behavior while transitioning from being new to becoming experienced by educating self about routines and policies while managing patient workload with little or no peer or leadership support and explained that these experiences were ‘eye openers’ both personally and professionally in terms of future practice. They described a culture that did not support the new nurses instead, the culture existing within the professionals was to primarily allow the new nurses to succeed or fail on an individual basis and not to offer individual support, acceptance or collaboration. The participants termed it as ‘individual cultural sense’, different but just as destructive as the culture of blame that was generally prevalent in the workplace. Nurses strongly advocated for support systems to be incorporated in workplaces where newcomers should be welcomed and encouraged by senior members of the nursing staff.

9.3 Workplace culture, survival and moving on

Nurses described a common atmosphere of censure and reproach encountered day to day during patient care both in the nursing homes and acute care facilities which was not just limited to medication error incidents. Some nurses described situations where they experienced behaviors of incivility by nurse managers and senior nurses towards them. Nurses emphasized that survival of new nurses in such a challenging work atmosphere is almost impossible and frequently forces new nurses to leave their jobs.

“... as a new nurse there was time management, bullying, that is just there and then, umm…just trying to learn your trade as well as the real-world side of it... and being so unsure of myself...it could happen to anybody...I’ve seen it happen to, you know, experienced nurses as well...”

Nurses were also, greatly concerned that because interruptions and distractions have become so commonplace and such a part of most workplaces in the healthcare arena, that leaders often fail to recognize these as significant factors that may result in most medication errors. Nurses in this study described experiences where they encountered and overcame challenging situations while caring for patients as they moved forward in the practice arena. Nurses also said that they understood the challenges of practice and recognized various barriers present in the current healthcare system and asserted that staff nurses must be included in discussions while addressing common patient issues for safe professional practice. Similar concerns by nurses were reported in previous studies addressing medication errors [22 , 23 , 11 , 24 , 21] .

Nurses strongly expressed that patient care should not be an individual responsibility rather a team effort where members of the healthcare team may be able to depend on each other to deal with critical patient care situations owing to the busy and sensitive workplace environment and explicitly stated the need for change from a toxic environment to one that was just and supportive. Nurses attributed error occurrences to lack of collaboration among healthcare team members in terms of following correct protocol or individual team members following a different protocol or being unaware of the protocol. Nurses in this study stated that most organizational systems currently in place are possibly not very conducive to safe patient care practices, and strongly suggested the utilization of experienced frontline staff nurses in care related discussions to build future safe practices.

9.4 Communication and teamwork, voicing concerns without fear

Nurses in this study expressed concerns about not being able to voice concerns or express their opinions regarding medication errors or other patient care related issues because they were not invited to be a part of discussions vital to their patients.

“…definitely, get their (nurses) input, because they are the ones doing the medication administration, so they have to really be involved in the whole process ... input as far as the policies and procedures and umm…the nurses know the workflow, so you have to go to the nurses!... You have to talk to the nurses because they know what they actually did!”

This markedly draws attention to the fact that nursing is not involved directly in discourses or discussions where patient care concerns are addressed. This aspect is clearly reported by previous medication error studies [3 , 25] .

Participants in this study asserted that nurses’ involvement in patient care and care related decisions should always be a primary focus which is less likely to be successful without effective communication and teamwork. Nurses stated that workplaces that lack communication and teamwork create major barriers for safe and effective patient care which invariably results in medication and other types of errors that compromise patient care. Nurses strongly believed that even though much system improvements have been made, medication errors are still prevalent because nurses are excluded from discussions related to these occurrences. Nurses uniquely and explicitly advocated that having conversations with those nurses who were involved in medication error incidents would be an excellent way to better understand the circumstances that predisposed to the medication error occurrences. Participants felt that nurses’ input is most essential to equip units to reduce such incidents which, going forward would assist organizers and leaders to effectively improve existing work conditions as well as assist nurses to gain back selfconfidence and be able to voice concerns without intimidation from colleagues or supervisors.

9.5 Governance and collegiality

Nurses asserted that staffing decisions are commonly made by nurse leaders where nurses are frequently assigned to different set of patients on the same unit or moved out of the unit to staff another floor which disrupts the continuity of care and work routine. They (staff nurses), on the other hand are not allowed to organize or manage the care of their own patients. This disrupts teamwork and frequently leads to inconsistencies in work routine generating distractions that may promote error occurrences due to unfamiliarity of patients and patient care routines.

“...poor judgment and assigning too many patients with similar names to the same team... you have two nurses a team with 28 or 29 patients, we don’t have a cap in the emergency room.”

“... ‘cause when you have a different nurse, she doesn’t know the patient- she doesn’t know the floor, she doesn’t know the unit or the procedures, what goes on, on that floor, so she tends to be more fidgety and nervous and anxious!”

Literature reviewed reports several studies that have identified disruptions, distractions and interruptions as causes of medication errors and identifies them as the leading cause of medication error. Some studies recommend restructuring nursing and educating staff nurses as well as incorporating specific protocols to reduce medication errors [25 - 28] .

This study highlighted participants’ experiences where nurses explained that because patient care units were constantly busy it was extremely challenging to administer medications safely and simultaneously care for patients especially those that were critically ill with multiple care needs. Nurses expressed distress at the unfair treatment by peers while a few expressed gratitude for being treated fairly and said that support is much needed in times of crisis. Nurses strongly felt that difficult situations warranted coordinated teamwork and collegiality which would help significantly to manage patient care and avoid medication error incidents. Participants suggested involvement of nurses in creating processes for safe medication administration and said that nurses are the persons who understand the medication administration process better than anyone else. Nurses also stated that because they are often the second victims who experience the errors along with patients, they should be the designated change agents to help promote safe medication administration process. Nurses further asserted that adequate staffing as well as a collegial and supportive workplace environment free of intimidation is extremely essential to reduce medication errors.

9.6 Professional security

This study revealed nurses’ concern about the wellbeing of their patients when a medication error/s occurred because they were aware of their responsibility towards the safety of patients. However, nurses were also extremely concerned about their professional security which was mostly generated from a fear of being held accountable if patient was harmed by the error and the culture of blame prevalent in the workplace.

“...people are afraid of losing their jobs, so they’re not gonna say anything or they’ll just be prone to making more errors because the environment is not conducive to one’s learning, for safe practice (blame) and for people to feel comfortable…to say, “ok I made a booboo, don’t, don’t kill me!”

All participants in this study agreed that underreporting of medication errors was largely due to an underlying fear of losing one’s job. These findings were identified by previous medication error studies [20 , 29 , 2] .

Most participants in this study described a general atmosphere of hostility in the workplace where nurses were against nurses and the workplace culture was that of animosity and antagonism towards each other. Nurses felt that one wrong move may jeopardize their job because they were either new to practice or new to the unit and were constantly made to feel that they needed to prove themselves to their colleagues. Nurses felt that they were being set up for failure which rendered them incapable of handling patient situations professionally. Nurses described feelings of being unwanted and undeserving of the RN position mostly after the medication error incident and felt that senior nurses tried to make them look incompetent in the sight of the nurse manager as if they committed a misdemeanor. Nurse colleagues often tried to implicate them in multiple ways which generated insecurity and a fear of losing their professional status. Participants believed that maintaining a job status was more important than being hired as a RN for the first time. Nurses in this study strongly suggested that healthcare leaders need to strengthen frontline staff nurses by eliminating the culture that exudes constant criticism, reprimand and rebuke and inculcate the workplace environment with collegiality and support.

10. Study Limitations

This study was conducted in the USA, state of New York therefore; the transferability of the results globally may be questioned due to variations in the healthcare systems prevailing in other countries. Another possible limitation of this study may be related to the selfselected sample, which may be viewed as subject to bias as the nurses involved in medication errors may have projected exclusive individual attitude owing to the unique nature of these experiences. Additionally, those nurses who volunteered to participate in this study might have demonstrated a strong interest in medication safety. Meanwhile, those nurses who were less confident and forthcoming in wanting to share their experiences may have been unintentionally excluded from this study. Finally, the researcher’s professional experience as a nurse of several years with multiple roles and responsibilities may be viewed as subject to bias.

11. Implications and Recommendations

11.1 nursing practice and healthcare organizations.

It is common knowledge that making errors is part of the human experience therefore; nurses and other healthcare professionals being humans may commit medication errors. According to Reason [30] there are two ways to view causes of human errors. The person approach attributes the errors to individuals (culture of blame) and the system approach assess deficiencies in the existing systems and recognize individuals to be fallible (just culture). Research suggests that perceptions of a safe patient care environment and safety culture in healthcare facilities vary among staff nurses and nurse leaders because of differences in their viewpoints which is a major deterrent to quality patient care and a concern among staff nurses [31 , 32] . Other medication error studies were found to be linked to lateral violence and bullying [33 , 34] .

Present-day healthcare system has metamorphosed in numerous ways, the most significant of which is the eminence of RN roles and responsibilities of patient care. This transformation calls for frontline nurses to be leaders at the bedside with full dominion and responsibility of patient care. The findings of this study suggest that nursing practice and healthcare organizations consider the following recommendations:

• Provide at all times, adequate staffing on units, not only based on numbers but also consider the acuity and diversity of the patient population to enable prioritization of care and teamwork while providing safe and quality care to all patients.
• Remodel workplace culture to champion collegiality among all members of the nursing team as well as among the interdisciplinary healthcare team members for better and improved patient outcomes.
• Restructure to build a non-toxic, blame free and stress-free culture in workplaces enabling nurses to voice patient related concerns and be change agents for better patient outcomes.
• Organizational and nurse leaders may create and/or incorporate programs that provide staff nurses with learning experiences of high caliber and quality for the continued enhancement their management skills to encourage professional growth and safe quality patient care.

11.2 Nursing education

Being that nursing students have restricted and supervised exposure to patients, it is a common observation that they acquire very limited experience in the care of patients. Therefore, it is vital that new graduate nurses should be guided and supervised by experienced nurses, especially in the first year of nursing practice [35 , 36] . Participants in this study revealed new realizations with implications for nursing education that underscored the importance of educating student nurses who are about to graduate in a way that they can anticipate and overcome obstacles while entering practice to reduce medication error incidents. The findings of this study recommend and/or suggest that nursing educators may consider the following recommendations:

• Qualitative medication error studies about nurses’ lived experiences may be conducted in other states of the USA, other countries and globally for a varied perspective of medication errors in other healthcare systems currently across the USA and worldwide.
• Quantitative medication error studies to compare and correlate medication errors to staff nurse concerns about patients and nurses across the healthcare systems.
• Research studies to further investigate medication error categories to understand what really constitutes a medication error in the administration process and staff nurse involvement.
• Studies for in-depth investigation of medication errors from the perspective of student concerns to understand challenges of transition into practice. This may assist nurse educators to formulate ways for seamless transition of new nurses into practice.

12. Nursing Research

Research suggests that there is paucity of studies related to nurses’ lived experiences and perceptions of making medication errors in the USA and globally. The following are recommendations to consider for further research:

13. Conclusion

Research suggests that even though healthcare organizations continue to diligently work towards improving the existing systems, medication errors continue to be the highest and most common predictable cause of medical errors of which administration errors are the leading cause of all medication error occurrences. This poses a significant question for the healthcare organizations and leaders to burrow beyond the surface to identify and address the factual causes of medication errors that are embedded within individual organizational setups and develop novel ways to resolve these issues. This study identifies important issues that are relevant to medication errors and recommends ways to reduce medication error incidents through the descriptions of the lived experiences of nurses that were involved in medication errors to build a future of a safer patient care environment in contemporary healthcare systems.

Competing Interests

The author declare that there is no competing interests regarding the publication of this article.

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The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Abbas al mutair.

1 Research Center, Almoosa Specialist Hospital, Al-Ahsa 36342, Saudi Arabia

2 College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh 12214, Saudi Arabia

3 School of Nursing, University of Wollongong, Wollongong, NSW 2522, Australia

Saad Alhumaid

4 Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa 36342, Saudi Arabia; as.vog.hom@diamuhlaas

Abbas Shamsan

5 Research Center, Dr. Sulaiman Al Habib Medical Group, Riyadh 12214, Saudi Arabia; [email protected] (A.S.); moc.liamtoh@aiz-ra (A.R.Z.Z.); [email protected] (A.A.-O.)

Abdul Rehman Zia Zaidi

6 College of Medicine, Alfaisal University, Riyadh 12214, Saudi Arabia

Mohammed Al Mohaini

7 Basic Sciences Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Alhasa 31982, Saudi Arabia; moc.liamg@076maam

8 Basic Sciences Department, College of applied Medical Sciences, King Abdullah International Medical Research Center, Alhasa 31982, Saudi Arabia

Alya Al Mutairi

9 Department of Mathematics, Faculty of Science, Taibah University, Medina 54321, Saudi Arabia; as.ude.uhabiat@iriatuma

Ali A. Rabaan

10 Microbiology Department, Johns Hopkins Aramco Healthcare, Alhasa 31982, Saudi Arabia; moc.liamg@naabara

11 Department of Public Health and Nutrition, The University of Haipur, Haripur 22610, Pakistan

Mansour Awad

12 Commitment Administration, General Directorate of Health Affairs, Ministry of Health, Medina 54321, Saudi Arabia; as.vog.hom@2iriatumlaaaM

Awad Al-Omari

Associated data.

Not applicable.

Background: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. Conclusion: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

1. Introduction

Medical errors are described as unintentional mistakes either by omission or commission. Medical errors are classified into an error of execution or an error of planning, which are explained as the unsuccessful process of deliberate action or utilization of an improper plan to attain a goal, respectively, or by deviating from the process of care that may potentially cause harm to the patient [ 1 ]. In 2008, the US Department of Health and Human Services Office reported 180,000 deaths by medical errors among hospitalized patients [ 1 ]. A high percentage of medical errors is attributed to medications that account for almost 1.5 million victims of medical errors every year [ 2 ]. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” These events can be linked to procedures, healthcare commodities, professional practice, along with systems consisting of prescription, order communication, dispensing, monitoring, product labeling, distribution, compounding, administration, nomenclature and packaging, education, and use. These events can be linked to healthcare commodities, procedures, professional practice, along with systems started with nomenclature and packaging, storing and distributing, prescribing, transcribing, documenting, reviewing, preparing (or compounding), product labeling, educating, dispensing, and ended with drug administration and monitoring [ 3 ]. Medication errors significantly impact the well-being of individuals, organizations, and healthcare systems. According to an NCCMERP report, medication errors are ranked the sixth cause of mortality in the United States, with 5–10% of the reported medication errors classified as harmful [ 3 ]. Recently, medication errors have become a challenge facing healthcare systems and are directly linked to hospital mortality and morbidity rates [ 4 ]. Specifically, medication errors cause adverse effects on hospitalized patients and weaken the public’s confidence in the healthcare system and the healthcare services being provided [ 5 ]. In addition, medication errors negatively impact clinical outcomes such as length of stay (LOS), incurring substantial costs of about USD 2000-2500 per patient [ 2 , 6 ]. Another issue is the high proportion of underreporting of medication errors (estimated to be 50–60%) across healthcare organizations that is attributed to the lack of medical recording systems in many hospitals [ 2 ]. Therefore, different prevention programs were implemented to monitor errors targeting triggers and/or influencing factors of medication errors [ 7 , 8 , 9 , 10 ] through using carefully formulated establishment-wide reporting systems to find the likely sources of medication errors [ 11 ]. Although the reporting of medication errors offers usable data for identifying areas of improvement with regard to patient safety, the advancement of patient safety is impeded and the lack of formal reporting is well recognized [ 12 ]. A variety of standards at the institutional level and a higher level of government exist for designing an effective medication error reporting system [ 12 ]. Simultaneously, the transformation of medication error reporting systems is required to facilitate easily preventable mistakes and their often-severe aftereffects [ 12 ]. Thus, understanding what hinders reporting could eventually result in superior patient care [ 12 ]. Whilst plentiful reports have studied the contributing factors [ 7 , 8 , 9 , 10 ], rates of prescription errors, and adverse events [ 13 , 14 , 15 ], insufficient researches have analyzed the characteristics of successful medication error reporting systems.

2. Material and Methods

2.1. aims and objectives.

In order to give basic details about the medication error reporting culture, incidence reporting systems, effective reporting method(s), analysis of medication error reports, and also suggest recommendations to improve medication errors reporting systems, we conducted a review of currently available literature evidence.

2.2. Search Strategy

A total number of five electronic databases (PubMed, Ovid, EBSCOhost, Embase.com, and ProQuest) were methodically searched for articles using components derived from the subsequent subject headings and keywords: characteristics, effective, error, improve, medication, report, reporting, successful, system. Furthermore, we searched citations from relevant papers to select additional studies. The search remained limited to English language journals published between January 1998 and June 2020.

2.3. Inclusion and Exclusion Criteria

Readily accessible peer-reviewed, full-text articles in the English language, primary research publications of any design (quantitative and qualitative studies: observational cohort or case-control studies, clinical trials, cross-sectional and systematic reviews) were included. We looked for studies that reported medication error reporting culture, incident reporting systems, creation of effective reporting methods, analysis of medication error reports, and recommendations to enhance medication error reporting systems. The studies identified in the search were manually evaluated for applicability in this article. We also included limited articles that concentrated on medical—not medication errors and nursing practice errors. We eliminated conference papers, editorials, letters to the editor, organizational reports, opinion papers, and case reports.

2.4. Data Extraction and Analysis

Two reviewers (AA and SA) individually vetted titles with abstracts followed by a full article review, where any doubt remained. Disagreements between two reviewers after full-text vetting were resolved via unanimity by a third reviewer (AS) and a fourth reviewer (ARZ). The data extraction involved evidence in each relevant selected article on medication error reporting systems, reporting culture, creating an effective reporting method, analysis of medication error reports, and/or recommendations to improve medication errors reporting systems. To examine the literature, a narrative synthesis was performed due to the variety of instruments and reported data. A narrative synthesis is characterized by the textual methodology that delivers a trustworthy tale of the findings from the selected literature [ 16 ]. Additionally eligible studies were appraised using critical appraisal tools. The appraisal consists of 10 items that assess the methodological quality of a study and determines the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis. The results of the appraisal have been taken into full account and used to inform the synthesis and interpretation of the results of the recommendations.

3. Results and Discussion

Overall, we screened 5 literature databases and identified 684 articles. A total of 384 duplicated articles were excluded from the review. Then, 300 articles evaluated for possible inclusion using title and abstract. 180 articles were selected for full-text vetting, resulting in the 60 articles comprising the narrative review ( Figure 1 ). An estimated 120 articles were omitted after full-text screening (reasons: conference papers, editorials, letters to the editor, organizational reports, opinion papers, and case reports = 80, not relevant to hospital settings = 17, focused on an error concerning a specific medication or associated with a specific medical condition = 14, or study with no relative data = 9). Articles were published from 1998 to 2020 with a summit of papers between 2006 and 2014. Articles largely came from the United States and the United Kingdom, with fewer studies from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt.

3.1. Reporting Culture

A system for reporting medical errors can lead to future detection of the possibility of a medical error occurring [ 17 , 18 ]. However, patient safety is not developing fast enough to face future challenges in healthcare [ 19 ]. In the past, medical errors were rarely disclosed; nowadays, however, failing to disclose an error in the hospital is considered a violation of the code of ethics and leads to litigation [ 17 , 20 ]. Nevertheless, do all healthcare providers divulge medical errors? The decision of disclosing a medical error by a healthcare provider is problematic [ 17 ]. Fein and others discussed the most effective factors that influence decisions on disclosing a medical error, which fall into four categories; provider elements, patient elements, error elements, and institutional culture [ 17 , 18 , 19 , 20 , 21 ]. There is an absence of reporting medical errors in the medical field and factors influencing motivation to report medical errors have been investigated in several countries. Around 16–20% of nurses fail to report incidences [ 22 , 23 , 24 , 25 ] because they fear being terminated by employers. Some healthcare providers fail to report an incident because of a lack of management feedback [ 22 , 25 , 26 ], unsupportive colleagues [ 26 ], lack of time [ 25 ], and lack of knowledge [ 27 ]. In order to realize the development in such an area, cultural changes have to be made; feeling safe to report a medical error and learning from past mistakes are crucial factors that might improve patient safety [ 19 , 28 ]. One of the controversial problems in reporting systems is whether reports should be mandatory or voluntary. Mandatory reports might lead to litigations [ 29 ] and may destroy the doctor-patient relationship, which can lead health care providers to practice “defensive medicine” [ 29 , 30 ]. Ethically and professionally, healthcare providers should not be obligated to report medical errors. Voluntary reporting is beneficial for medical learning and promotes a culture of safety. On the other hand, mandatory reports have shown the effectiveness of participation in reporting medical errors. For example, in Denmark the reporting rate is 50% compared to 1% in Australia, where the reporting is voluntary [ 19 ]. England has changed its policy of reporting from voluntary to mandatory, and if there is a failure to notify the error, the medical Trust may face the consequence of a £4000 penalty. To have organizational accountability and to improve patients’ safety and effective prevention systems, the two reports “To Err is Human” and “An Organization with a Memory” both suggested the utilization of a compulsory reporting system in harmful accidents [ 19 , 30 ].

3.2. Incidence Reporting Systems

Incidence Reporting Systems (IRSs) have been known to minimize incidences in air flights; hypothetically, it would also decrease the medical errors in the healthcare systems [ 31 ]. Nowadays, medical error reporting systems are widely used. The New Zealand Pharmacovigilance Centre (NZPhvC) is the national center responsible for monitoring adverse reactions to medications in New Zealand, through the Centre for Adverse Reactions Monitoring (CARM) [ 32 ]. In Australia, the Advanced Incident Monitoring System (AIMS) was implemented around 2005 [ 31 ], and the National Reporting and Learning System (NRLS) is used since 2003 in the United Kingdom [ 31 ]. Additionally, in Ireland, the National Adverse Event Management System (NAEMS) (formally known as STARS web IRS) was implemented and has been in use since 2004 [ 31 ]. Several years back in the United States, the Medical Event Reporting System for Transfusion Medicine (MERS-TM) and United States Pharmacopeia’s MEDMARX Reporting System were introduced. The different systems the United States has launched can be represented as a high level of knowledge in reporting systems [ 33 , 34 ]. There are two kinds of reporting systems, voluntary and mandatory. The most significant systems are designed after the Aviation Safety Report System (ASRS) which is run by NASA for the Federal Aviation Administration; the system is voluntary and anonymous [ 35 ]. Several voluntary systems are being modeled after the Aviation Safety Report System (ASRS) such as, the Veterans Administration Patient Safety Reporting System (PSRS) [ 36 ], the Institute for Safe Medical Practice (ISMP) which is designed for medical error reporting [ 37 ], and Data Watch which is established by the United States Food and Drug Administration (US FDA) for documenting of contrary occasions stemming from medicines and therapeutic devices [ 38 ]. The Canadian Medication Incident Reporting and Prevention System (CMIRPS), which is involved in nationwide preventable medication error occurrences and reporting, was established by Health Canada, ISMP Canada, and the Canadian Institute for Health Information (CIHI) [ 39 ]. Furthermore, in Egypt, neonatal intensive care units (NICUs) utilize the Egyptian Neonatal Safety Training Network (ENSTN), which can be used confidentially and anonymously to report medical errors [ 40 ]. In Saudi Arabia, the National Pharmacovigilance Center (NPC) was established by the Saudi Food and Drug Authority (SFDA) to monitor for surveillance of the safety matters of medications and it plays a vital role in the identification of adverse drug reactions (ADRs), their evaluation and prevention [ 41 ]. Many countries such as Greece [ 42 ], Korea [ 43 ], Japan [ 44 ], and France [ 45 ] have adopted similar systems which have shown substantial positive benefits [ 46 , 47 , 48 , 49 ].

3.3. Creating an Effective Reporting Method

Creating an effective multiple-phase reporting method to lower medication errors can act to identify the baseline rates of prescription errors. Hence, this can enable a recognition of the major types of medication errors and thereby assist in risk-reduction through the application of various preventive measures [ 50 ]. A successful strategy to prevent and detect drug-related problems may involve three stages: pre-intervention phase, intervention phase, and post-intervention phase [ 51 ]. The pre-intervention phase reinforces voluntary medication error reporting in the healthcare facility by healthcare professionals utilizing standardized forms. Reports must be continuously monitored, reviewed, and documented on a daily basis throughout the pre-intervention phase [ 51 ]. During the pre-intervention phase, medication handling stages are monitored, patient records will be reviewed, and all procedures will be documented. The incident(s) and types of medication error(s) within the healthcare facility will be identified. Quantitative and qualitative analyses of the collected reports should be carried out during the intervention phase [ 50 , 51 ]. Multiple quantitative and qualitative data analyses can be applied here based on the data available, such as quantitative root-cause analysis or qualitative content analysis. Root factors that contribute to prescription errors that have caused or have had the possibility to cause harm “near miss” to the patient can thus be realized [ 50 ]. The intervention phase is an integral corrective phase as it should consist of training programs for the targeted healthcare providers [ 51 ]. Training programs should be directed towards the identification of medication errors, causation, the harm inflicted, and the importance of effective communication to promote patient safety parameters within the healthcare facility. The post-intervention phase ought to embrace continuous monitoring after the intervention corrective phase [ 51 ]. It should also emphasize the re-collecting of data and comparing it with the pre-intervention data. This phase studies the adherence of staff to voluntarily report the incidents of medication errors. The incident is then reported nationally through the organization’s system or online electronic-form.

4. Analysis of Medication Error Reports

NCCMERP has developed a medication error taxonomy tool to aid healthcare workers and organizations characterize, trace, and analyze medication errors in a standardized, methodical approach [ 52 ]. The taxonomy is useful for developing a medication error database and designing an error reporting or data collection form. Healthcare organizations should build systems and procedures to accumulate ample information required to inspect and report medication errors at the time the events occur (ideally, all the elements identified in the taxonomy). One key component of the taxonomy, which categorizes an error in accordance with the severity of the outcome on a scale from A to I, is the NCCMERP medication index [ 52 ]. Factors such as whether the error got to the patient and if the patient was affected by the error and to what level, are considered by the index. The use of the NCCMERP medication error-index is encouraged in all healthcare delivery settings [ 52 ].

5. Recommendations to Improve Medication Errors Reporting Systems

Every medical institution should aim towards implementing methodologies whereby patients are not put at risk due to medication errors. Healthcare organizations should proactively eliminate these by investigating errors that have both occurred and those that may potentially occur. This way, it is possible to identify methods by which the consumption of medicines is incorrectly reported and thus mitigating the health risks patients are exposed to. A consistent organizational framework is needed to monitor and measure medication safety. Encouraging reporting, monitoring, and open discussion of medication errors is key in establishing a culture of safety. The system will improve with more data entries; these can be from existing errors already known, ones that may have been missed earlier, and even other miscellaneous errors. The following ( Table 1 ) depicts a list of necessary factors that should be considered based on the findings explored by other academics [ 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 ].

Characteristics of Successful Reporting Systems.

5.1. Blame-Free or Non-Punitive Culture

A system that can properly evaluate and rectify errors needs to be non-punitive if is to provide meaningful, applicable data [ 53 ]. There should be a system where blame is not assigned to those experiencing the errors or those that annotate them. Priorities of an effective medication error reporting system need to target pre-emptive and retroactive actions as opposed to placing blame on an individual. Corrective actions can prevent an incident recurrence, mitigate prescription errors, and enhance the long-term well-being of patients, thus improving their quality of care [ 54 ].

5.2. Anonymity

The reporting system should also consider maintaining anonymity in the reporting incident data, allowing the reporter to remain anonymous while reporting the medication error [ 54 ]. A lesson can be learned from Australian and British work on “open disclosure” and “being open”; this will help individuals to enhance their understanding as the majority of these are unintended and can later be seen with transparency [ 55 ].

5.3. Responsive and Productive

A responsive medication error reporting system stimulates internal reporting within a health organization significantly [ 56 ]. Analysis of these reports needs to be undertaken urgently, especially those that are found to be at a more critical or detrimental level; these reports, in turn, need to be made readily available to those that can take appropriate action. The response should be visible, useful, and constructive for the health care system change [ 56 ].

5.4. Encourage Involvement

Patient safety is the responsibility of everyone in the healthcare organization. Engaging key stakeholders will increase the acceptance of the priorities and result in the successful implementation of improvement efforts [ 57 ]. Key stakeholders can include the patient safety officer, chief executive officer, chief nursing officer, chief operating officer, chief medical officer, director of pharmacy or chief pharmacy officer, and the Pharmacy and Therapeutics (P&T) Committee chair. Thus, it can be seen that including patient education in as many programs as possible (both medical and non-medical) is of the utmost importance [ 57 ].

5.5. Accountability

Coordinating with senior leadership is needed to develop formal or informal authority to ensure that any unsafe practices are evaluated and immediately addressed if necessary [ 57 ]. Developing a mechanism for holding others accountable through committees or senior leaders is essential to the success of medication safety efforts [ 57 ]. Through proper education and subsequent guidance, patients themselves will be trained to prevent such medication errors and aid both the personnel and the system that is designed to help them [ 57 ].

5.6. Create an Environment That Supports Reporting

With the advent of modern technologies and infrastructure, it is imperative to utilize such data analyses to further attenuate medication errors. This is more possible now than ever; especially in the way that computerized physician entries tie in with the barcoded distribution of medication and conciliate one another [ 58 ]. Hospitals that utilize mechanics such as aided journal entries and an appropriate system helping them make decisions have been shown to alleviate complications and mortality rates and consequently reduce operating expenditure [ 59 , 60 ]. An organizational reporting system should be made user-friendly and accessible to all employees, students, and teaching staff (if not employees) [ 58 ]. System design changes should be considered to make it easy and meaningful to report; for example, minimize the number of screens or paper pages required for reporting, balance the need for detail with ease of use, and utilize check-boxes or drop-downs [ 59 ]. These methodologies will be most effective when every user is well-versed in the running and systemic architecture of the system [ 59 ].

5.7. Review Summary on a Regular Basis

When working to enhance a medication error reporting program, the focus should be on increasing the reporting and analysis of reports that did not result in patient harm, with the goal of decreasing harmful events [ 60 ]. Excessive focus on trends and ‘the numbers’ through monthly statistical reports can be counterproductive if it results in a de-emphasis on the analysis of root causes that can lead to corrective actions and process improvement [ 60 ]. However, a review of summary information on a quarterly, semi-annual, or annual basis is often helpful to refocus safety improvement efforts as well as identify areas of the organization that are underreporting [ 61 ].

5.8. System-Oriented

To fully enhance the system and keep it in a state of improvement, it is essential that individuals feel that they are not being held responsible. They should feel empowered to improve the different facets of the system [ 61 ]. Doing so will create culture of safety to be accommodated at an individual level [ 61 ]. This will also reinforce the concept that despite an error occurring due to human individual error, it would be replicable at some point due to the deficiencies present in the reporting system [ 61 ].

5.9. Expertise

There needs to be experts in place that can properly assess the clinical requirements of an individual case and the fundamental system architecture that allowed this to exist in the first place [ 50 ]. Such a job requires technically-aligned experts if a reporting system is to be fully utilized [ 50 ].

5.10. Psychological Safety

Psychological safety should be made a requirement of healthcare organizations. Essentially it is “being able to show and employ one’s self without fear of negative consequences of self-image, status, or career” [ 62 ]. Implementing these core values allows the workplace to be one where there is both trust and respect afforded to those who are part of it [ 62 ]. Doing so allows the whole mechanism of reporting systems, in its giving and receiving feedback and identification of errors, to be further enriched [ 62 ].

5.11. Enough Resources

The implementation of reporting systems without adequate resources will not be useful [ 63 ]. The analysis and understanding of the root/core reasons of why various errors are occurring are paramount and need an appropriate level of due-diligence afforded; such improvements may rely on fine margins and thus need attention [ 63 ].

5.12. Physical Wellbeing

Healthcare providers need to have good concentration and physical wellbeing, particularly in an emergency situation [ 64 ]. Deterioration of healthcare providers’ awareness or memory coordination may impact their performance and result to mediation prescription and administration errors [ 65 ]. Previously published research has revealed that sleep deprivation among healthcare providers is linked with medical errors occurrence [ 66 ]. There is an evidence that night-shift healthcare workers commit medical errors more often than their dayshift counterparts as they experience poorer quality and shorter duration of sleep [ 67 ]. Therefore, offering shorter periods of time on a night-shift and less working hours may lead to better sleep quality and less occurrences of less medication errors.

Limitations

As with any review, this one has some limitations. The review mainly focused on the various reporting systems and recommendations to improve medication error reporting systems. Due to the wide-net this encompasses, a narrative approach was preferentially adopted over a more systematic literature search. This preference was favored as it allowed the inclusion of evidence; conversely, this meant there was the possibility of a bias arising when selecting the different studies, and we were not able to evaluate the strength of the evidence reported. The literature present on this topic is vast and as such, it is our recommendation to further explore this topic academically to gain a more informed understanding of the various topics discussed within this report. Thus, these medication errors along with the systems in place that allow them to propagate can be further explored, giving an informed, better understood wide-scale picture that can then be implemented. Furthermore, the use of English language papers only may have impacted the richness of the data included in this review.

6. Conclusions

Medication errors are a common problem that places a massive burden on healthcare systems and are often avoidable by implementing effective preventive strategies. A critical tenant to measure the effectiveness of a reporting system is to measure how effectively the attained information is implemented to enhance patient safety. A successful medication error reporting program has the following characteristics: safe for the reporter, results in useful recommendations and effective changes, includes everyone, and is supported with required resources. Organizations must adopt a successful reporting environment for the medication use process to evolve into a safer practice. It is the responsibility of the organization to provide an environment to its users’ where reporting is conducted in a systematic, ever-evolving manner so that medication is prescribed using a safer infrastructure.

Acknowledgments

The authors declare no conflict of interest in preparing this review article, authors also thank the referee for constructive comments. The authors would also like to thank Sulaiman Al Habib Medical Group’s Research Center ( https://www.hmguae.com/ , accessed on 5 August 2021) for their tremendous support.

Author Contributions

A.A.M. (Abbas Al Mutair), S.A., A.S., A.R.Z.Z., M.A.M., A.A.M. (Alya Al Mutairi), A.A.R., M.A. and A.A.-O. made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; and agree to be accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest in preparing this article.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Medication Errors: Let’s Chat

Gilberto Buzzi,

Guest Host of #ebnjc Twitter Chat on Wed., June 21 at 8pm UKM time

Senior Lecturer – Adult Nursing, School of Health and Social Care, London South Bank University, 103 Borough Road, London, SE1 0AA, t: +44 (0)20 7815 6739 | e: [email protected]

Medication Errors

Ever experienced the terrors of been involved in a medication error, particularly one that had the potential to result in patient harm? If so, it is likely that you remember that moment quite vividly which may even have left you traumatized. These are some of the worse situations healthcare professionals may find themselves in as it goes against every core principle of their moral and professional duty. An entire section of The Code for Nurses and Midwives is dedicated to the preservation of patient and public safety and the importance of self-awareness to reduce potential harm associated to their practice (NMC, 2017), nonetheless, medication errors are still common.

In a review of medication error incidents reported to the National Reporting and Learning Systems (NRLS) over six years between 2005 to 2010 there were 525,186 incidents reported. Of these, 86,821 (16%) of medication incidents reported actual patient harm, 822 (0.9%) resulted in death or severe harm (Cousins et al 2012). A report commissioned by the Department of Health estimated the costs of preventable errors in the NHS, particularly relating to improper use of medication, to be around £770 millions a year, but most importantly, medication errors can cost lives.

“Medication errors occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death” (WHO, 2017). This suggests that medication errors could be preventable at different levels. Whilst there is robust legislation and guidelines to ensure patient safety particularly in relation to the administration of medicine, following simple and practical steps such as the 10 rights of Medication Administration can greatly reduce the risk of errors and literally save lives. These are:

• Right patient: Ask patient to identify themselves and check the name on the prescription and wristband. Ideally, use 2 or more identifiers.
• Right medication: Check the name of the medication and the expiry date with the prescription. Make sure medications, especially antibiotics, are reviewed regularly.
• Right dose: Check appropriateness of the dose using the BNF or local guidelines. If necessary, calculate the dose and have another nurse calculate the dose as well.
• Right route: Again, check the order and appropriateness of the route prescribed.
• Right time: Check the frequency of the prescribed medication. Confirm when the last dose was given.
• Right patient education: Check if the patient understands what the medication is for and who to contact in case of side-effects.
• Right documentation: Ensure you have signed for the medication AFTER it has been administered. Ensure the medication is prescribed correctly.
• Right to refuse: Ensure you have the patient consent to administer medications.
• Right assessment: Check your patient actually needs the medication. Check for contraindications. Baseline observations if required.
• Right evaluation: Ensure the medication is working the way it should and reviewed regularly. Ongoing observations if required.

Points 1 to 5 refer to NMC standards for medicine management. Points 6-10 are additional checks that have been adopted by multiple US nursing boards and research panels to enhance patient safety .

References:

Cousins, D.H., Gerrett, D. and Warner, B. (2012) A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010). British Journal of Clinical Pharmacology, 74(4): pp. 597–604

Frontier Economics (2014) Exploring the costs of unsafe care in the NHS. [online] London, pp.1-21. Available at: http://www.frontier-economics.com/documents/2014/10/exploring-the-costs-of-unsafe-care-in-the-nhs-frontier-report-2-2-2-2.pdf [Accessed 10 Jun. 2017].

Nmc.org.uk. (2017). Read The Code online. [online] Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ [Accessed 10 Jun. 2017].

World Health Organization. (2017). Medication Without Harm: WHO’s Third Global Patient Safety Challenge. [online] Available at: http://www.who.int/patientsafety/medication-safety/en/ [Accessed 10 Jun. 2017].

Standards for medicine management: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-medicines-management.pdf

Report a problem with a medicine or a medical device: https://yellowcard.mhra.gov.uk/ https://yellowcard.mhra.gov.uk/

Medicines & Healthcare products Regulatory Agency: https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency

Interesting read: https://www.zebra.com/content/dam/zebra_new_ia/language-assets/en_gb/solutions_verticals/Verticals_Solutions/healthcare/guide/mobile-printing-solutions-guide-en-gb-emea.pdf

https://www.england.nhs.uk/wp-content/uploads/2014/03/psa-sup-info-med-error.pdf

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=68464&type=full

http://www.pharmaceutical-journal.com/news-and-analysis/medication-errors-cost-the-nhs-up-to-25bn-a-year/20066893.article

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Nurses' medication errors

Affiliation.

• 1 University of St. Andrews, Fife, Scotland.
• PMID: 8014314
• DOI: 10.1111/j.1365-2648.1994.tb01116.x

This paper reports on a qualitative study of nurses' experiences with medication errors. Using discourse analysis within a framework of an interpretive research design, the phenomenon of a not too uncommon occurrence in nursing practice was examined. Insight into nurses' involvement with medication errors was gained from interviews, group discussions and self-reports. Documents of disciplinary proceedings, where the Professional Conduct Committee of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting has dealt with incidents of medication errors, supplemented the data. Decisions made in situations of medication errors have moral implications at personal, institutional, and professional levels. The moral courage that is needed to learn from mistakes can be enhanced through honest dealings with the situation. Where the attention is shifted from the person involved onto the problem at hand, fair judgement may be advanced and the fear of owning up to a mistake be diminished. Only when reflected upon, can personal experience merge into the stream of development and progress. This study contributes to such reflection. Three key issues are discussed in-depth as they evolved during analysis of the data: These issues deal with identification and change; with guilt and shame and the reconciliation with human precariousness; and with teaching and learning. The manner in which discourse analysis was used here represents an innovative attempt to advance qualitative methodology in nursing research.

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