Factors contributing to medication errors: a literature review

Drug administration is an integral part of the nurse's role. Responsibility for correct administration of medication rests with the nurse, yet medication errors are a persistent problem associated with nursing practice. This review examines what constitutes a medication error and documents contributory factors in medication errors. These factors have been derived from reported medication errors and opinions of nurses as to factors which predispose to errors. A number of definitions exist as to what constitutes a medication error. The definition used should facilitate interpretation and comparison of a wide range of research reports. Medication errors are a multidisciplinary problem and a multidisciplinary approach is required in order to reduce the incidence of errors.     

Double checking medicines: defence against error or contributory factor?

Rationale and aim  The double checking of medicines in health care is a contestable procedure. It occupies an obvious position in health care practice and is understood to be an effective defence against medication error but the process is variable and the outcomes have not been exposed to testing. This paper presents an appraisal of the process using data from part of a larger study on the contributory factors in medication errors and their reporting.
Methods  Previous research studies are reviewed; data are analysed from a review of 991 drug error reports and a subsequent series of 40 in-depth interviews with health professionals in an acute hospital in northern England.
Results  The incident reports showed that errors occurred despite double checking but that action taken did not appear to investigate the checking process. Most interview participants (34) talked extensively about double checking but believed the process to be inconsistent. Four key categories were apparent: deference to authority, reduction of responsibility, automatic processing and lack of time. Solutions to the problems were also offered, which are discussed with several recommendations.
Conclusions  Double checking medicines should be a selective and systematic procedure informed by key principles and encompassing certain behaviours. Psychological research may be instructive in reducing checking errors but the aviation industry may also have a part to play in increasing error wisdom and reducing risk.     

Improving the quality of drug error reporting

Background Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. Aim The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. Methods A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi‐disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. Results The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems‐based. Staff felt obliged to report but rarely received feedback. Implications and conclusion Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi‐centred evaluation.     

我院护理给药差错管理办法的实施与效果

目的有效控制护理给药差错的漏报率，提高住院病人的安全。方法成立护理给药差错评定小组，强化护理人员的安全意识，扩充有效的给药差错报告渠道，细化奖惩细则及评价标准。结果实施护理给药差错管理办法后，给药差错漏报率有明显降低，差异具有统计学意义（P〈0．01）。结论合理的护理给药差错管理办法能激励当事人和科室管理者主动上报差错的发生情况，使护理给药差错管理纳人良性循环。     

Nursing student medication errors involving tubing and catheters: A descriptive study

This retrospective case study examined reports (N = 27) of medication errors made by nursing students involving tubing and catheter misconnections. Characteristics of misconnection errors included attributes of events recorded on MEDMARX^® error reports of the United States Pharmacopeia. Two near miss errors or Category B errors (medication error occurred, did not reach patient) were identified, with 21 Category C medication errors (occurred, with no resulting patient harm), and four Category D errors (need for increased patient monitoring, no patient harm) reported. Reported intravenous tubing errors were more frequent than other type of tubing errors and problems with clamps were present in 12 error reports. Registered nurses discovered most of the errors; some were implicated in the mistakes along with the students.     

二级医院132例给药差错环节分析及管理对策

目的：分析给药差错各环节中存在的关键风险点,为护理管理者制定防范给药差错的管理措施提供依据。方法：收集上海郊区8家二级医院2009年1月至2011年6月主动上报的给药差错,分析各环节发生差错的原因。结果：共收集到132例给药差错,其中发生在用药环节的差错最多,占56．06％;发生在配置环节的差错占25．00％;发生在转录环节的差错占18．94％。结论：在给药流程的各环节中,始终存在给药差错的风险,护理管理者应根据可预见的风险,梳理给药过程各环节的风险要素,加强给药环节管理,从多元素、多角度着手,管理和防范关键风险点。     

Intravenous medication errors in the emergency department,knowledge, tendency to make errors and affecting factors: An observational study

BackgroundIntravenous medication errors are common in hospital settings particularly emergency department. This study aimed to determine intravenous medication preparation and administration errors, contributing factors, tendency towards making errors and knowledge level of emergency department healthcare workers.MethodsA cross-sectional study using a structured, direct observation method was conducted. It was conducted with 23 emergency healthcare workers working in the emergency department of a university hospital in Turkey. Data were collected by questionnaires: Knowledge Test on Intravenous Medication Administration, Intravenous Drug Administration Standard Observation Form, Drug and Transfusion Administration Sub-Dimension scale, Perceived Stress Scale and Pittsburgh Sleep Quality Index.ResultsIt was determined that the knowledge level of the emergency healthcare workers about intravenous medication administration was moderate, and the tendency mistakes regarding drug and transfusion applications was very low. There was no relationship between education level, years of work, years of work in the emergency department, perceived stress level and sleep quality, and the tendency of making mistakes in drug and transfusion applications.ConclusionIt is important for patient safety to prevent medication errors by determining the factors affecting intravenous medication administration, tendency to make mistakes and knowledge levels, which are frequently used in emergency department.     

住院病人静脉药物治疗给药错误环节分析与对策

目的分析住院病人静脉药物治疗过程中发生给药错误的环节,为制订改进措施提供依据。方法回顾性分析某三级甲等医院过去5年护理非惩罚性主动上报静脉药物治疗给药错误环节、给药错误类型及发生给药错误原因。结果静脉药物治疗发生给药错误的环节由高到低依次为：护士给药操作、护士医嘱处理、护士配药、医生开具医嘱、药房配药发药、病人依从性差;发生给药错误涉及护士、医生、药师、病人;给药错误类型为：药物错误、遗漏给药、发错病人等,操作不规范和流程设计不合理是发生给药错误的主要原因。结论由护士失误引起的给药错误所占比例最高,特别是由护士个人完成的环节,给药错误发生率最高;整体理念是研究预防给药错误发生对策的关键,提高护理管理水平,减少给药错误的发生要从多方面考虑。     

Frequency of pediatric medication administration errors and contributing factors

This study examined the frequency of pediatric medication administration errors and contributing factors. This research used the undisguised observation method and Critical Incident Technique. Errors and contributing factors were classified through the Organizational Accident Model. Errors were made in 36.5% of the 2344 doses that were observed. The most frequent errors were those associated with administration at the wrong time. According to the results of this study, errors arise from problems within the system.