Emergency Department nurses’ perceptions of what constitutes a medication error: Implications for establishing safer medication delivery systems

By Jeff Bouman, Pharm D, RN

Recent patient safety literature reports medication error rates as high as 1.9 errors per inpatient day leading to 7,000 deaths per year. The literature is replete with data highlighting the importance of collecting information on all types of medications errors, including those that do not reach the patient and those that reach the patient but cause no harm, in order to improve the safety of medication delivery systems. Despite efforts to collect more and better data, the majority of medication errors continue to go unreported.

Because nurses administer most medications in the hospital setting, they are an excellent source of information on medication delivery systems. The work environment in hospital emergency departments (EDs) is particularly conducive to distractions and interruptions. In addition, EDs typically do not have direct pharmacy involvement in medication administration. I conducted a study focusing on emergency department nurses’ perceptions of medication errors.

The objective of my study was to determine ED nurses’ perceptions about:

Study Design

ED nurses from two different campuses of a metropolitan pediatric hospital were asked to complete a survey about these items. I developed my survey questions based on my review of previous studies (references available upon request) that looked at reasons behind medication errors, comparing these various reasons to my personal experience as a nurse. Dr. Todd Sorenson of the University of Minnesota College of Pharmacy reviewed my questions for clarity and conciseness.

The survey consisted of three sections:

Section I: What is a medication error?

Respondents answered three yes-or-no questions about their understanding of medication errors:

Respondents then read two scenarios describing “near misses” and indicated whether either scenario described a reportable error or not:

Scenario 1: You give a patient twice the ordered dose of Tylenol. After discussing this with the physician, you both agree that no harm will come to the patient.

Scenario 2: You bring cefuroxime to the patient’s bedside instead of the ordered ceftriaxone. You notice that you have the wrong medication and are able to switch medications before administering.

Respondents were then asked to estimate the percentage of medication errors occurring in the ED that are reported.

Section II: Why do medication errors occur?

Respondents ranked by frequency items on a list of potential causes of medication errors:

Section III: What are barriers to reporting?

Results (see appendix below for charts and graphs)

What is a medication error? Of 47 respondents, 98% agreed or strongly agreed that they knew what a medication error was. However, only 65% regarded the Tylenol overdose as a reportable error, and only 35% regarded the cefuroxime “near miss” as a reportable error. Respondents perceived that 89% percent of medication errors that do occur in ED go unreported.

Why do medication errors occur? Many of the possible reasons why medication errors occur were ranked as factors by respondents, including both individual and system issues. Of reasons ranked “usually” or “always” a reason, failing to follow the “5 Rights” and provider handwriting were the significant individual issues, and interruptions and miscommunication between staff were the significant system issues identified.

What are barriers to reporting errors? Trends about barriers to reporting were much more clear. Time constraints were identified as the most significant barrier, followed closely by three barriers reflecting confusion about what constitutes a reportable error: uncertainty about what to report, error unlikely to cause harm, and prescriber did not express concern. These two issues (time and uncertainty about what to report) were considered twice as likely to inhibit reporting as the fear of consequences of reporting (impact on employment, licensure, and relationships with peers, as well as lawsuits).

Discussion

What is a medication error? The majority of nurses surveyed do not regard “near misses” as reportable medication errors. This, combined with the fact that the majority of nurses believed that medication errors are not fully reported, indicates that current initiatives to build safer medication delivery systems are missing vital information.

Why do medication errors occur? When exploring factors contributing to medication errors, people tend to focus on individual performance rather than system problems. For example, failure to observe one or more of the 5 Rights of medication administration has its own list of possible causes that includes system issues as well as individual performance issues or knowledge deficit.

What are barriers to reporting errors? Making the process as succinct and user-friendly as possible can alleviate time constraints as a barrier to reporting. Electronic reporting is promoted as the most efficient way to collect, collate, and communicate safety data, but for the caregiver at the bedside, electronic reporting is more burdensome than paper reporting unless computers are readily accessible without wait time and the electronic form is brief.

The tendency to withhold reporting of events that did not cause harm (as judged by the nurse or communicated by the caregiver via “not expressing concern”) is not strongly driven by fear of consequences to the reporter. Therefore, initiatives to increase the reporting of good catches and near misses should concentrate on knowledge deficits about the learning value of these events rather than on fear of reporting.

Indications for further research

Conducting studies similar to mine in all patient care areas where medications are administered would generate valuable information about nurses attitudes toward medication errors in other practice settings. We need to re-evaluate how we educate nurses about medication errors – not only new nurses, but regular, periodic continuing education for all nurses.

Appendix

Section I: What is a medication error?

Scenario 1: You give a patient twice the ordered dose of Tylenol. After discussing this with the physician, you both agree that no harm will come to the patient.

Scenario 2: You bring cefuroxime to the patient’s bedside instead of the ordered ceftriaxone. You notice that you have the wrong medication and are able to switch medications before administering.

Section II: Why do medication errors occur?

Section III: What are barriers to reporting?