MEDICATION ERRORS

Administering medication is a high risk activity for nurses.

One third of errors that cause patient harm occur during the administration of medication by nurses.

It is the most common cause of unintended harm to patients.

And there is no easy solution for the individual nurse to prevent the institutional processes that are placing patients at risk.

It is easy for the organisation to blame the nurse when the error is made.

There is a forensic examination that occurs by the organisation about what the nurse did that was wrong.

But that same forensic analysis rarely occurs to the organisation’s responsibility for its actions in failing to provide a safe environment for patients and nurses.

Why do organisations allow nurses to be constantly interrupted when they are performing a high risk activity such as medication administration?

It is interruptions that are one of the main contributing factors to high medication error rates.

It is the organisation’s responsibility to intervene and create a culture where nurses can focus on the task that they are performing.

Instead of nurses being constantly interrupted, the organisation should be providing an environment where non-urgent tasks do not take priority over what is a high risk activity.

Of course there will be those who say that the nurse should be able to manage the situation.

And the nurse should be taking personal responsibility for managing the high rick activity.

But nurses who have competing activities as a result of the acute nature of the patient’s conditions and high workloads are more likely to experience distractions and interruptions.

Other distractions and interruptions are not something that individual nurse’s can be held be responsible for.

Any high risk activity would have a set of protocols about how the activity should be ideally managed.

Imagine the difference that it would make if medication administration had a set of standards that included solutions to minimising interruptions that were organisation specific.

Just like hand washing between patients is strictly enforced, so would activity around medication administration.

Environmental attributes that lead to medication errors are the responsibility of the organisation.

These attributes are

  1. poor lighting
  2. high noise levels
  3. restricted drug storage space
  4. cluttered work surfaces
  5. poor layout of medication rooms
  6. a lack of space for preparing and charting medications
  7. lack of privacy in medication rooms.

The individual nurse should be aware of these but it is the organisation that has to change them.

There is often confusion about what constitutes a medication error.

One study found that only 1 in 5 nurses said that the following were medication errors:

  1. A patient having missed an antibiotic dose due to the fact that he was away from the ward for three hours.
  2. A dose of medication delayed by 45-60 minutes.
  3. An dose of nebulised medication at 2am omitted because the patient was sleeping. 

The organisation should have clear guidelines about what constitutes a medication error.

The reasons for medication errors are many.

And the reasons may seem trivial or unimportant in isolation.

But when combined together, those reasons lead to adverse events that no one wants.

To learn more about medication error:

Cloete, Linda. “Reducing medication errors in nursing practice.” Nursing Standard 29.20 (2015): 50-59.