The nurse’s role in medication safety

The process of medication delivery includes several components: prescribing, transcribing, dispensing, administering, and monitoring. One-third of all medication errors occur during the administration phase of medication delivery.²

The National Coordinating Council for Medication Error Reporting and Prevention 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.

Nurses need to recognize the challenges they face when administering medications to their patients. Because nurses consistently administer medications, they’re well positioned to prevent medication errors.³ Nurses must be prepared to not only catch their own errors, but also the errors of healthcare providers, pharmacists, and others in the chain of medication administration.

This article defines medication errors and near-miss events, explores human and environmental factors contributing to medication administration errors, and discusses the nurse’s role in minimizing errors.

Statistics on medication errors in U.S. hospitals are difficult to calculate, due to the variability in reporting. In 1999, the government released a report titled To Err is Human: Building a Safer Healthcare System, which stated that approximately 98,000 people die each year in the United States due to medical errors (Institute of Medicine [IOM], 1999). Based on the IOM report, it is now estimated that as many as 440,000 deaths occur each year due to medical errors (James, 2013). Studies estimate that approximately 19.1% of these errors are medication administration errors (Keers, Williams, Cooke, & Ashcroft, 2013).

A cross-sectional study was done with 203 nurses to examine medication knowledge and the risk of medical errors. Participants were from acute care hospitals and primary care settings. As part of the study, each participant was given a test on pharmacology, drug management and drug calculations. The study showed that the participants had a 39% moderate risk and 11% high risk for pharmacology knowledge, 33% moderate risk and 26% high risk with drug management, and 32% moderate risk and 7% high risk with drug calculations (Simonsen, Johansson, Daehlin, Osvik, & Farup, 2011).

As nurses, we are often the last “gatekeeper” in the administration process to prevent medication errors. It is important to take the time needed to ensure patient safety, and to minimize distractions throughout the process. Here are strategies on how to prevent medication errors in nursing:

• The rights of medication administration. Initially, there were five rights for administration including the right patient, drug, time, dose and route. A sixth right is the right reason. Some literature describes up to 12 rights, including education, documentation, right to refusal and expiration date.

• Independent double checks. The Institute for Safe Medication Practices (ISMP) (2014) recommends the use of redundancies, such as independent double checks of high alert medications due to the increased risk for patient harm. This includes independent calculations for dose and rates of medication. The list of high alert medications can be found at http://www.ismp.org/tools/institutionalhighAlert.asp

• Medication review. Practices include comparing the medication administration record and patient record at the beginning of a nurse’s shift; determining the rationale for each ordered medication, and requesting that physicians rewrite orders when improper abbreviations are used, are important strategies.

• Knowledge. A nurse should never administer a medication which he/she is unfamiliar.

• Patient education. Ensuring that patients and families are knowledgeable regarding the medication regimen so that they can question unexplained variances are also associated with lower rates of medication errors.

• Practice environment. A supportive practice environment, including teamwork between physicians and nurses; opportunities for nurses to participate in hospital- and unit-level decisions; continuity of patient care assignments; continuing education opportunities; and the retention of nurse administrators who are visible and accessible, who listen to nurses’ concerns, and who have high expectations of their nurses are associated with a higher quality of nursing care. (James, 2013; RWJF, 2012; Simonsen et al., 2011)

For more information on medication safety and how to avoid medication errors in nursing, check out these courses on RN.com: “High-Alert Medications: Safe Practices,” “Medication Safety: Assuring Safe Outcomes” and “Medical Error Reduction: A Key to Quality Care”

Intercepting a medication error before it reaches the patient is an example of a near-miss event. Often nurses aren’t aware that a medication error or near-miss event has occurred.⁵ Or they may not even know what constitutes a medication error.⁶ Without clear definitions, the degree of underreported medication errors can’t be fully recognized. This contributes to the inability to change key aspects of a complex medication delivery system.³

Literature review

Medication administration errors are the subject of much research. The traditional approach to medication administration includes the “five rights.” According to a strong consensus, these five rights are the right patient, drug, dose, route, and time; other rights are sometimes added, including right reason and documentation.³ However, none of these rights reflects the fundamental intricacies associated with the process of administering medications in a hospital setting, and they all fail to consider human and system factors.^3,5,7,8

Medication administration errors are underestimated and underreported. Explanations for underreporting include a lack of awareness that a medication error has occurred, unfamiliarity with medication administration error reporting processes, fear of legal ramifications, and fear of being perceived as incompetent.^3,5,6,9

About half of nurses are reticent about reporting medication errors because they fear disciplinary action.^6,9,10 In healthcare, a culture of fear and blame is associated with failure to report errors. A stigma is associated with making an error, and nurses perceive they’ll be a target for repercussions if they admit to making a mistake. For instance, the error could have a negative impact on the nurse’s performance evaluation. An Agency for Healthcare Research and Quality survey found that 50% of nurses thought mistakes are held against them, 48% felt the person making the error was being written up instead of the actual problem being reported, and 35% believe that these occurrences are recorded in their personnel files.¹⁰

Decades ago, Leape recognized this paradox in healthcare: The standard of practice in medicine and nursing is perfection—even though medical professionals acknowledge that mistakes are inevitable and most want to learn from these mistakes, ideally in an understanding and supportive environment.¹¹ Expecting error-free performance is unrealistic.

Reason used a Swiss cheese model to represent accident causation and illustrate how an error can slip through despite overlapping system defenses and safeguards.¹² Each slice of Swiss cheese represents a level of protection. However, safety gaps exist, and when gaps line up, errors occur. Unless a pattern of errors or evidence of reckless behavior occurs, a single event shouldn’t warrant disciplinary action or termination. This concept underlies the tenets of a “just culture.”¹³ Nurses must be able to learn from their own mistakes and from the mistakes of others.

Understanding human factors

Nurses must recognize their own roles in preventing medication errors.

• Reporting errors. In order for nurses to learn from their mistakes, they must be willing to disclose them; this in turn improves practice and ensures a safer patient care environment.¹⁴ Nurses have an obligation to look for risks, report errors or hazards, and help design safer systems.¹³ Nurses have a professional duty and moral obligation to report medication errors; not reporting medication errors increases liability and violates professional ethical standards. Furthermore, not reporting errors sets up other nurses to make errors and fails to improve the system.

Policies and procedures for medication error reporting should provide clear definitions for medication errors and near-miss events, and a means for delineating contributing factors, such as staffing and environmental conditions. A system for reporting and analyzing medication errors should be implemented in an efficient and user-friendly manner.

• Knowledge of pharmacology. Integrating pharmacokinetic and pharmacodynamic principles into clinical practice is essential for patient safety. Understanding the onset, peak, and duration of medication effects encourages timely medication administration and helps prevent the possible accumulation of adverse reactions. For example, knowing the rates of infusion for I.V. medications is critical for avoiding adverse reactions.

Being familiar with nursing implications for the medications nurses administer is critical for improved patient outcomes. For example, before administering furosemide, a nurse must check the patient’s potassium level because furosemide is a potassium-wasting loop diuretic. Lung sounds should be assessed before amiodarone administration. An apical heart rate must be obtained before administering digoxin. The patient’s BP must be assessed before administration of any antihypertensive medication.¹⁵

If the nurse isn’t familiar with a specific medication, many resources are available, including comprehensive drug guides. Hospitals commonly have electronic databases for medications. Smart phone users can consult drug reference applications to research unfamiliar medications.

Professional development classes at local community colleges or online classes strengthen a nurse’s understanding of pharmacokinetics and pharmacodynamics. Nurses have a duty to the patient to know the actions and indications of all medications they administer, including safe dosage ranges, adverse reactions, monitoring parameters, and nursing implications.

• Recognizing perceptual factors. Misperceptions are at the root of many medication errors. For example, a nurse using the medication dispensing system to obtain hydralazine retrieves the wrong drug because a pharmacy technician had inadvertently filled the drawer with hydroxyzine instead. The nurse incorrectly perceives that the correct drug was retrieved because that was what the nurse expected to find in that drawer. Another example of an error based on perceptual factors is when hydralazine and hydroxyzine appear on the screen of the automated dispensing system in alphabetical sequence and, because the drug names are so similar, the nurse inadvertently selects the wrong drug.

The mind can easily be fooled by the illusion created by familiarity, expectancy, similarity, and experience; this phenomenon is known as confirmation bias or inattentional blindness.¹⁶ In other words, the brain sees what it wants to see because of four factors: conspicuity, mental workload, expectation, and capacity.¹⁶ It’s the failure to see something because attention isn’t focused on it or the brain inadvertently filters out important information.¹⁶ Essentially, this is a kind of optical illusion that occurs when the brain “auto-corrects” for what the nurse expects to see. Examples of confirmation bias that contribute to medication errors include look-alike and sound-alike drugs, decimal point placement, units of measurement, size and type of font, incorrect drug calculations, frequency of administration, similar packaging, and the use of unapproved abbreviations. The nurse may see the drug name on the label, drug, or dose but interpret it incorrectly.

• Human factors. According to The Joint Commission’s analysis of root causes by event type, human factors account for 73% of all medication errors.¹⁷ Human error is unintentional and unpredictable; it’s simply a mistake.¹³ During medication administration, human errors are attributed to the complex, multistep system processes established in the hospital.^3,5 The human mind is fallible and has limitations. Errors result from poor attention span, inadequate communication, faulty reasoning, reduced memory, insufficient training, fatigue, and inexperience.^5,9,14,18 Nurses identify distractions, fatigue, and exhaustion as frequently contributing to medication errors.⁵ Nurses should avoid conversations with others, as well as rushing and trying to do anything else when preparing and administering medications. Above all, nurses should never prepare medications for more than one patient at the same time.

Drug calculation errors fall into this category as well. Nurses who aren’t confident in their math abilities should confirm any drug calculations by asking a peer to double-check the calculation, verifying the correct dosage with the pharmacy, or consulting a drug book to validate a safe dose range. Nurses should follow institutional policy regarding the need to seek independent verification of dosage calculations for those medications deemed to be high risk in their practice setting. The Institute for Safe Medication Practices has a complete list of high-risk drugs on its website (https://www.ismp.org/tools/institutionalhighAlert.asp).

For medications given as a continuous infusion, most infusion pumps have safety features such as preprogrammed drug libraries with alerts established for doses considered dangerous or ineffective. Nurses shouldn’t ignore or disable these important safety features. Equally important is ensuring the previous nurse programmed the rate correctly based on the designated protocols for titration.

Healthcare professionals often fail to clarify orders, prescriptions, directions, and reporting parameters. Components of a medication order include patient, drug, dose, frequency, route, parameters, and any necessary labs for monitoring if indicated. For example, if a nurse is administering vancomycin, the patient’s renal function studies must be assessed before starting therapy and periodically during therapy. If these results aren’t available, the nurse must know to request these lab test results from the healthcare provider.

The quality of team communication and improved clinical outcomes are related, making it essential for a nurse to clarify ambiguous communication. The Institute for Healthcare Communication reports that ineffective communication is the root cause for almost 66% of all medical errors between 1995 and 2005.¹⁹ The Joint Commission published a sentinel event alert in 2008 highlighting intimidating and disruptive behaviors contributing to medical error and adverse events.²⁰ Quality of patient care is dependent on teamwork, communication, and a collaborative work environment.²⁰

Understanding system and environmental factors

The medication administration process involves multiple decision points that increase the potential for error. Patients are admitted to the hospital with increasingly complex medical conditions and medication regimens that create a very dynamic medication administration record.

Brady et al. reported that the lack of clinical decision supports, inadequate checks and balances, reliance on manual documentation, and insufficient information system infrastructures reduce the ability to interpret medication orders correctly.⁹ Recent technology has addressed these early concerns. Medication management systems, computerized provider order entry, bar coding, electronic medical records, and workstations-on-wheels improve efficiencies and minimize the potential for error by giving nurses access to information in real time.

Advances in technology, however, create a whole new set of risks and error potentials. Initially, computer processes may be time consuming, but ultimately they can improve patient safety.⁷ Nurses must resist the temptation to develop workarounds during the learning curve that comes with new technology. When a system issue interferes with safe medication administration, nurses must report the problem so improvements can be implemented.

Nurses can also ensure a safe environment by reducing distractions, improving lighting, and minimizing noise levels.⁵ The area where nurses prepare medications should be quiet and have good lighting. To improve safety, a medication room should have only one medication dispensing system. Medication rooms with more than one medication dispensing system become high-traffic areas, increasing the risk of distraction resulting in a medication error.

Reaching solutions

To ensure a safer environment for medication preparation and administration, the first step is for nurses to examine their work environment and reflect on their current practice of medication administration.

Streamlining the medication error reporting process can facilitate reporting actual or potential errors. Error reporting addresses complex system issues and improves patient outcomes by minimizing the likelihood of the same event being repeated.

To reduce the risk of human error, nurses must be attentive, support each other when mistakes occur, and stop tolerating workarounds and other risky behaviors. Heightened awareness of error-prone conditions and recognition of contributing factors in the medication administration process are essential to patient safety.