Factors Influencing Nurse Medication Errors
Submitted by Skip Morelock PhD, RN, NEA-BC
Clinical Professor of Nursing
Nurses are intimately involved in the medication administration process. Even though the parameters of selection, dosing, compounding, and dispensing medication remain under the purview of other allied health professionals, the nurse represents the last safety checkpoint between the medication and the patient and efforts should be directed toward removing obstacles which are negatively impacting this process. It has long been suspected that nursing distractions whether by patient, family, coworkers or others, are facilitating the occurrence of errors in the hospital setting. There are practices which are discussed which may ameliorate this threat to some extent if employed consistently and judiciously.
Despite the widespread implementation of electronic medication delivery systems and a standardized approach to medication administration, errors are still occurring which are impacting patients (Flynn, Liang, Dickson, Xie & Suh, 2012). This despite evidence that other forms of hospital-acquired complications such as bloodstream infections and pressure ulcers have markedly decreased since 2010 (Cohn, 2015). This report will review some of the latest research emanating from key United States healthcare facilities and will synthesize the more salient findings as well as posit possible solutions to this still present problem.
There is little question that the Institute of Medicines seminal report on medication errors and patient harm in 1999 catalyzed the development and deployment of a wide variety of automated systems which were designed to remove most failures in medication dispensing, delivery, and administration. Many of these systems seem to operate on the premise that nursing care is robotic and proceeds in an orderly and consistently linear fashion. Patient care in the real world seldom adheres to this rigid blueprint. It is the observation of this author, and supported by contemporary nursing literature, that nurses are being interrupted at nearly every critical juncture in the medication administration process and often have to craft highly creative solutions to work around this problem. This in turn may compromise the integrity of the process and open the door to error occurrence.
What kinds of medication errors are most frequently occurring? Edwards & Axe (2015) found that the five most common medication errors were unclear prescriptions, wrong dose being transcribed, incorrect frequency, drug omission or delays in drug administration. Two of these errors seem to originate with the physician or the prescriber of the medication. One study showed that 17.3% of wrong patient errors were provider related (Yang & Grissinger, 2013). Similar findings by Unver, Tastan & Akbayrak (2012) found that prescribing/dosing errors made up 15% of errors, but that 82.6% of errors were the result of medication omission or incorrect administration time. The last two are clearly nurse-sensitive indicators. Omission is a fairly clear-cut construct. The nurse does not administer an ordered medication. Incorrect administration time is more complex and involves many other factors. As an example, if a nurse has three intravenous antibiotics to administer at 9:00 in the evening and the patient has 1 intravenous access site and the antibiotics arrive from pharmacy at 8:00, it is not possible for the nurse to administer all three antibiotics (safely) by 9:00. Even with a 30 minute administration window either side of the scheduled time, it would not be possible to administer all of the ordered antibiotics within the timeframe. Technically, any of the drugs that were not administered in this time frame would count as a medication error. It is true that the nurse could insert another intravenous line to expedite medication administration, but what if the patient has limited veins to access or if the physician refuses to order a central intravenous line or a peripherally inserted central catheter (PICC)? Pharmacists also play a key role in this as they should have the vested authority to alter medication administration times when it is obvious that the medications cannot all the given safely in the time prescribed. Additionally, most state boards of nursing maintain that the nurse must have a working knowledge of any drug they are administering to the extent that they are able to accurately assess desired efficacy, potential side effects, as well as know when a dose seems suspect or incorrect (Agency for Healthcare Research and Quality, 2013; Texas Board of Nursing, 2015). The expectation is that a nurse would call the provider and request clarification. If clarification was not given and the nurse was still uncomfortable about the order, then the facility’s chain of command would be activated. These requisite interventions can represent a significant amount of time. So the conclusion is even if it is a provider problem, it is clearly a nursing problem as well.
Ideally, the flow of care should proceed as follows. The licensed independent practitioner electronically enters a medication order for a particular patient. This generates a message to the facility pharmacist who then reviews the order and then either permits access to the medication by the nurse or delivers the medication to the appropriate cell or bin in the automated medication dispensing system. The nurse can then retrieve the medication, scan the patient’s armband and determine that it is the correct patient and then scan the medication to insure that it is the correct dose, then administer the medication to the patient followed by timely documentation of the process in the electronic health record (Gann, 2015). This process can be inordinately cumbersome especially considering the nurse may have 4 or 5 other patients who also require medications not to mention other aspects of patient care which do not involve medication administration such as toileting, ambulation, dressing changes, safety checks, and patient/family teaching.
There seem to be 3 main obstacles which impinge on the nurse’s time and ultimately affect the process of medication delivery. The first are sudden and unpredictable changes in the patient’s or another patient’s condition which merit rapid intervention and may interrupt the medication administration process mid-stream. The nurse may be in the middle of the medication administration process when informed that another patient is having difficulty. The nurse stops what they are doing and rushes to the scene of the patient with the immediate need. This type of interruption makes it difficult to maintain the ordered timeliness of the medication delivery since the nurse will have to manage the existing emergency, and then go back to the patient, and likely initiate the medication administration process all over again or return in the middle of the process, thus increasing the chance that the nurse will omit a critical step in this process and possibly cause an error. In one study, the nurse was interrupted a total of 43 times in a 10 hour period (Tucker & Spear, 2010). Other studies showed that 17% of all medication administrations were interrupted in some way (Young, Cochran, Mei, Adkins-Bley, Ciarkowski et al, 2015). It is unreasonable to think that this type of interruption can ever be completely eliminated, but it can be reduced. Early warning systems which are designed to pick up on the sometimes subtle clinical cues that may herald a deterioration in a patient’s condition are being implemented in many hospitals. The MEWS (Modified Early Warning Score) scoring system (Gardner-Thorpe, Love, Wrightson, Walsh & Keeling, 2006) can be built into a hospitals electronic health record to auto-extract physiological data at pre - determined intervals and issue an alert to the nurse when a threshold score is reached. In this way, interventions can be initiated which might have the effect of preventing deterioration to the point of requiring an emergency intervention. Alternatively, the patient could be moved to a higher level of care when signs of clinical deterioration present. The overall goal being to reduce emergency clinical situations which may have the effect of distracting the nurse during medication preparation and medication administration rounds.
Another type of interruption are when well-meaning families insist on persistently asking the nurse about the patient when the nurse is trying to calculate the correct dose of a drug or adjust an intravenous medication. This is especially prevalent in critical care units where vasoactive medications are being titrated at frequent intervals based on existing protocols and families are naturally concerned about how their loved one is progressing. Family members may not even be aware that this type of interruption can cause a nurse to commit a potentially dangerous medication error. Family members should be gently instructed to not interrupt the nurse when adjusting a medication. Some hospitals have implemented a system where if a nurse is at the medication dispensing machine, calculating a medication, titrating or adjusting an intravenous drip, or is in the patient/medication scanning phase of the medication administration process, it is understood that they are not to be interrupted (Bower, Jackson & Manning, 2015; Bravo, 2016; Cloete, 2015). While this sounds workable in theory, operationally it might be difficult to implement effectively and consistently. Unfortunately, interventions which purport to reduce interruptions during the medication administration process have not shown to be very effective (Raban & Westbrook, 2013). Additionally, hospitals might be slow to implement any actions which, at least superficially, may seem to discourage patients or families from asking questions. The implications of medication misadventures however should outweigh any concerns and more robust research is needed to determine the best solutions for this continuing problem.
The final type of interruption occurs when a physician, nurse, other provider, or staff member interrupts the nurse in order to relay insignificant or inconsequential information either related or unrelated to the patient that is being care for. Tucker & Spear (2010) found that when physician’s interrupted nurses during medication administration to relay redundant messages such as “I have written new orders” often had the effect of making the nurse feel frustrated and demeaned as they are well-aware of the need to check for new orders and the procedure for checking new orders is hardwired into their daily practice. Other unnecessary or non-emergent interruptions from coworkers should be kept at a minimum during this time and this tactic should be firmly and consistently reinforced by nursing and unit leadership.
Several strategies have been proposed and implemented which purport to reduce the chances of a nurse becoming distracted while administering medications. One of the most popular is the donning of a brightly colored vest by the nurse while on medication rounds. The staff would be instructed on the rationale and detailed scripting passed on to patients, families and visitors to not disturb the nurse when in a vest as this meant that the nurse is involved in calculating dosages, procuring, or otherwise engaged in medication administration. Unfortunately, in some instances, this was misinterpreted by the patient and family members to never disturb any nurse (Raban & Westbrook, 2014). Clearly, this was never the intent. Another study found that interruptions actually increased when the nurse was wearing the vest ostensibly because visitors were curious about it and wanted to know why some nurses were wearing it and some were not (Yoder, Schaderwald, & Deitrich, 2015). Some facilities have chosen to outline in colored tape a perimeter around the automated medication dispensing machines as a reminder to not interrupt the nurse when selecting and withdrawing medications for a patient. This may be effective in that small area, but does not account for nor influence interruptions which might occur once the nurse moves away from this zone. Finally, some hospitals have the nurses wear a lighted lanyard which blinks when the nurse is involved in medication administration or medication calculation or titration (Umeda, 2014). Patients and family members are educated about the purpose of the blinking lanyards upon admission. This would seem to be less threatening or imposing than the ‘do not disturb’ notation on a vest. This may represent the best ‘meet in the middle’ action as it is less conspicuous than a brightly colored vest, yet still provides a prominent visual cue that the nurse is engaged in a highly important and potentially risky nursing intervention. Nurses must still be coached and empowered to use proactive communication measures while in the medication administration phase even if this includes asking the patient, visitors or coworkers to not interrupt until the process is complete. This would be especially important when titrating vasoactive medications in a critical care area or when preparing and administrating anti-neoplastics or other similar drugs where a high degree of precision is required.
Other studies suggest that a bundle of interventions designed to prevent nurse distractions might hold more promise and offer more sustained improvements (Freeman, McKee, Lee-Lehner & Pensecker, 2012). Certainly much success has been seen in clinical areas when bundles of disease-specific interventions are implemented. Sepsis identification and treatment, central line infections, as well as adverse patient ventilator events have been effectively reduced when behavioral and interventional bundles have been implemented and hardwired into nursing and physician practice (Kalich, Maguire, Campbell-Bright, Mehrotra, Caffey et al., 2010; Khan, Al-Dorzi, Al-Attas, Marini, Mundekkadan et al. 2016; Talbot, Carr, Parmley, Martin, Gray et al., 2015; Tang, Chao, Leung & Lai, 2015). A bundle for reducing nurse interruptions while administering medications might include the following elements: 1- a checklist to ensure that all elements had been covered, 2- clearly delineated areas dedicated to medication procurement and preparation, 3- staff education regarding the importance of not interrupting the nurse during these times, 4- an item of clothing clearly marked or visible which is worn by the nurse during medication administration, 5- no more than two individuals permitted in the medication room at a time, 6- patient, family and visitor education regarding the importance of not needlessly disturbing the nurse while procuring and administering medications, 7- electronic notification to the front desk of the unit that a nurse is involved in medication administration and 8- health unit secretary training on not forwarding calls to the nurse while engaging in medication administration. As with any bundle implementation, there should be a period of small tests of change to ensure that the bundle is operationally viable. Some elements may have to be revised or even rescinded while other unaccounted for actions may be revealed as being very important and may be added to the bundle. Smaller facilities may not have the requisite infrastructure to implement some of the recommendations. A list of stakeholders should be identified from the beginning to help manage the process forward and be ready to provide ‘just in time’ data to support the overall objectives and to provide a snapshot of the state of the system.
Conclusions and Recommendations
It is evident from the research that nurses are continuing to commit errors despite intense efforts to manage the problem. Future efforts should focus on less automation of nursing practice and more on empowering the professional nurse to implement strategies that unencumber the medication administration process. The implementation of a bundle of interventions designed to reduce unnecessary distractions should be investigated, tested and implemented if found to be operationally viable. While the problem is complex with many organizational actors involved, it is nothing less than an imperative that patients should expect complete safety and accuracy when given medications.
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