Glossary
Human error
The failure of intended actions to elicit a desired response, causing deviation from what is right or true (Reason 1997; Hansen 2006).
Medication error
“Any potentially avoidable event which may involve inappropriate use of medications causing actual or potential harm to a patient” (National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP] 2007; Meadows 2003).
Summary
The report ‘Medication Errors and the use of Electronic Medication Administration Records (e-MAR) on maintaining patient safety’ examines the incidence and prevalence of medication administration errors, contributing risk factors, suggests nursing error prevention strategies, and puts forward recommendations for safe practice and the use of e-MAR in regards to optimising patient safety. Medication errors remain the single most alarming safety concern for patients across Australian hospitals. This report proposes that medication administration is safer for both patients and staff as a result of the use of e-MAR. Literature illustrates e-MAR decreases error rates and increases the potential for “improved workflow, improved financial outcomes and a more efficient way or managing medication tasks”. E-MAR should be used in practice across all Australian hospitals settings to ensure optimum patient safety.
Introduction
This report provides a detailed analysis of current literature to examine the incidence, contributory factors, and associated adverse events of medication administration errors. Additionally this report suggests medication error prevention strategies, recommendations for safe medication administration, and proposes the benefits of implementing e-MAR into hospital settings.
Incidence of medication errors within Australia
Across the clinical setting within Australia; the frequency of medication errors “is of serious concern” (Joanna Briggs Institute, 2006). The incidence of medication errors remains unclear as valid and reliable evaluations of different studies on medication errors are extremely difficult due to the “differences in variables, measurements, populations, and methods” (ASHP Guidelines on Preventing Medication Errors in Hospitals). Many different types of errors can transpire at multiple stages of the medication process, that is, from prescribing to administration. The following statistics relate to the incidence of medication errors:
Contributing risk factors
The original sources of medication errors are multidisciplinary and multifactorial. ‘ASHP Guidelines on preventing medication errors’ refer to the following as risk factors for potential medication errors:
Associated adverse events and consequences
Medication errors can not only end negatively for the patient and family but additionally the administering nurse, allied health professionals, and the public at large. Medication errors can have a wide array of outcomes ranging from minimal clinical significance to fatal effects, depending on the clinical setting in which they transpire. Medication errors often leave patients with increased health costs and reduced confidence in the Australian health care system. In regards to the associated financial burden to the public, in 2006, ‘adverse drug events’ were totalled to cost the Australian public approximately “$350 million” (Hodgkinson, 2006). The effects of medication errors on the Registered Nurse (RN) involved can be extensive and traumatic. Not only can one lose self-confidence and self-respect, feel humiliated, accountable, and guilty but additionally endue legal ramifications and loss of job security. Such feelings greatly affect one’s self perception and ultimately affect the ability to safety practice.
Nursing medication error prevention strategies
The reduction of medication errors continues to be a central nursing issue in risk reduction and maintaining patient safety. RN’s are most frequently the health care professional who performs the final stage in the medication process, that is, administration. There are a number of nursing strategies one can implement to reduce the chance of a medication error from occurring:
Double checking with a second RN remains an imperative strategy in preventing medication errors when preparing and administering a medication, nevertheless it does not abolish the need for the implementation supplementary safety actions as human error is still a high risk.
In essence the five rights involve five crucial checks conducted just before administering a medication, that is, the right “medication, dose, patient, route and time” (Crisp and Taylor, 2006). However the ‘5 Rights’ are not enough on their own to avoid a medication error.
Wilson and Di-Vito-Thomas (2004) have implemented a sixth right; right response. The 6th right permits nurses to focus on the evaluation stage of medication administration. Evaluating the effectiveness of medications is a crucial step that is often ignored, the sixth right ultimately reiterates the “importance of taking responsibility for the administration of medications” (Wilson and Di-Vito-Thomas, 2004). The sixth right is not applicable in all situations however does accentuate that the medication process does not stop at administration.
Nurses utilising medication administration equipment must recognise the “opportunities for error” that may still potentially occur with the use of such devices. (ASHP Guidelines on Preventing Medication Errors in Hospitals)
If a patient queries or refuses a particular medication, the RN must “listen, answer questions and if appropriate, double check the medication order and product dispensed before administering” to validate that no avoidable error is made, that is, “wrong patient, wrong route, or dose is already administered” (ASHP Guidelines on Preventing Medication Errors in Hospitals). If a patient refuses to take a prescribed medication, the resolution should be documented appropriately.
Electronic Administration Records
E-MAR integrates the use of a “laptop or thin client computer onboard medication carts” to display and record medication administration information (ACP&P, 2007). Lists of patients are displayed on the screen whereby nurses can select from, after a particular patient is selected the medications to be administered is presented. Nurses can then advance with administration, ensuring they “crosscheck the information on the screen with the drugs selected from the cart and noting completed administrations” (ACP&P, 2007) on the e-MAR. Incompatible medications, dosages and allergies are audibly and visually alerted to the administrating RN ensuring patient safety. Furthermore E-MAR has the potential to eliminate errors made from misinterpretation of written and verbal orders as all the patients’ medication information is displayed in an organised and typed manner saving valuable time and reducing errors made from poor time management. In accordance to studies conducted by Greenfield (2007) e-MAR provides access to patient information at the bedside, ultimately “increases the accuracy, speed and safety of nursing care, decreasing the incidence of medication errors” (Greenfield, 2007).
Recommendations
Technology, such as e-MAR, has the potential to drastically improve the level of patient safety and reducing existing medication errors; however such computerised technology also has the prospect of creating new varieties of medication errors. To be deemed appropriate for use in all hospital settings, such technology should include detailed product information such as size, precise markings, colour, and generic and trade names into e-MAR so nurses can ensure crosschecks are made correctly (Galt et al. 2005).
In terms of paper medication charts, according to Leach, 2006, a nationwide medication chart would be a potentially successful way of reducing medication errors linked to poor documentation and illegible handwriting.
Eradicating the use of “unsafe abbreviations” (Abushaiqa et al. 2007) is a vital recommendation for reducing medication administration errors and would involve several members of the multidisciplinary team. Misinterpretation of “medication name, dosage or units would be avoided if universal abbreviations were utilised” (New South Wales Therapeutic
Advisory Group [NSW TAG] 2007). Therefore in order to encourage and facilitate patient safety universal and unambiguous abbreviations need to be used constantly.
According to Rainboth and DeMasi, 2006, a lack of mathematical skill is recognised as an area requiring improvement at the undergraduate level. By placing more emphasis on mathematical competency at an undergraduate level may ultimately reduce the risk of an error being made as a RN. Additionally mathematical proficiency must be maintained post graduation to ensure skills are kept current.
It is suggested nurses exercise the use of “quality improvement programs” as they provide “guidance for patient support, staff counselling, staff education, and risk management processes” when a medication error is identified (ASHP Guidelines on preventing medication errors in Hospitals). Such policies, counselling, education, and intervention programs should be established and utilised in all hospitals. (ASHP Guidelines on preventing medication errors in Hospitals)
Conclusion
This report has reviewed literature on medication administration errors across hospital settings with a focus on Australian prevalence, contributory risk factors, consequences, specific nursing strategies to prevent errors from occurring, the use of e-MAR and recommendations to decrease the chance of medication administration errors. Labelled as the leading cause of unintentional patient injury, medication errors are a “serious issue in nursing which needs to be addressed” (Fogarty and McKeon 2006). Although the probability of an error occurring is apparently low, the grave nature of the related consequences is sufficient to rationalise abrupt action.
A medication error can produce destructive results, not only threatening patients’ lives but additionally “jeopardising nurses’ confidence, job security and job satisfaction”. Nurses are the final line of defence before a medication is administered to the patient; therefore it is important that all errors are adequately recognised and specific nursing strategies are implemented to reduce medication error occurrences. Many nursing strategies already implemented across Australia include appropriate use of e-MAR, adequate “incident reporting systems” (Anderson and Webster, 2001), enhanced “mathematical preparation” (Rainboth and DeMasi, 2006), appropriate use of “guidelines and policies”, and a nation-wide “common drug chart” (Leach, 2006).
Such strategies already implemented across Australian Hospitals are showing great success in reducing the incidence and severity of medication errors, however due to the unpredictable nature of nursing and medical care, both human and technological; the risk of error “can never theoretically be reduced to zero” (Leape, 1995).
