Running Head: FACTORS CONTRIBUTING TO MEDICATION ERRORS

Factors Contributing to Medication Errors Made by Registered Nurses

Giuliana Davanzo, Ashley Fagert, Alesha Fulton, Olivia Gerke, and Sydny Paul

04/02/2018

NURS 3749: Nursing Research

Spring 2018

Dr. Valerie O’Dell

Abstract
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The purpose of this research was to examine the factors that contribute to medication errors

in the nursing profession. The relationship between the factors affecting the nurse, the factors

relating to the drugs themselves, and how to reduce the factors relating to medication errors was

examined. In order to conduct this research, ten research studies were used. It was evident that

many factors that affected a nurse contributed to more medication errors, these included: workload,

shift worked, hospital units, patient to nurse ratio, interruptions, and nurses being impaired by a

substance. It was also found that factors relating to the medications, for example the type and route,

had an increase in error. Evidence was found to support ways to reduce the factors contributing to

medication errors. There were many factors that were discovered, some that could be easy to fix

and some that would be more difficult. Reducing the number of medication errors starts by

exploring how they happen and what we can do to decrease them. In the end, the research showed

that multiple factors on the nurse and factors relating to the medication itself can cause an increase

in medication errors.

Factors Contributing to Medication Errors Made by Registered Nurses

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Medication errors are one of the most talked about situations in nursing. No registered

nurse wants to ever be associated with a medication error. This topic was researched to find out

what contributes to medication errors in hospitals and how the number of errors can be reduced.

The nursing profession is one that comes with a lot of stress and responsibility. Factors that

influence the nurse continue to add stress and therefore, can lead to more errors. Nurses need to

understand medications and how to properly administer them or this could lead to more medication

errors that could have been prevented. With new policies and technology, the goal is to reduce the

number of medication errors overall. This is a situation that can happen at any time and can be

detrimental to not only the nurse, but the patient. Factors that contribute to medication errors need

addressed in order to decrease the number of errors. To uncover the reason why there are so many

medication errors, and what causes them, the following research question was addressed: In RN’s,

what factors affect medication errors per shift?

Literature Review

Introduction

Medication errors are a major topic in nursing. They may not be seen or heard of but they

happen and many nurses fail to report them or don't recognize their mistakes. As defined by (NCC

MERP, 2018) “A medication error is any preventable event that can lead to improper or

inappropriate use of medication or patient harm while the medication is in control of the healthcare

professional, patient, or consumer”. Today nurses are practicing in more autonomy than in the past

and there is an increase in accountability for their actions. In the medication system, nurses act as

the last role in the system, therefore administering and monitoring reactions of the patient is the

legal responsibility of the nurse when administering medications (Souza, 4573). In order to address

this topic in the nursing profession, information was obtained through OhioLINK databases,
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specifically MEDLINE, OVID, and CINAHL Plus. Ten sources were used for data collection for

factors that contribute to medication errors in nursing. The factors that contribute to medication

errors include those affecting the nurse, those relating to the medication, and factors that reduce

the effects on medication errors.

Factors Affecting the Nurse

Medication errors are often a result of a combination of factors. These factors cause a

negative effect on the nurse. Factors that can affect the nurse include: workload, shift worked,

hospital units, patient to nurse ratio, interruptions, and nurses being impaired by a substance.

According to Jones (2009), the National Patient Safety Agency (NPSA) conducted a study in

England and Wales that found that one in ten medication administrations result in error. From this

study it concluded that 59.3% of errors occur during the administration stage which could be “in

result of the increasing number of medications available and the new routes of administration”

(Jones p. 40). In another study conducted by Bolandianbafghi, Salimi, Rassouli, Faraji,

Sarebanhassanabadi (2017), “high workload, low numbers of staff, nurses, physical or mental

fatigue, and prolonged working hours were the major cause for medical errors” (p. 5145).

Nurses constantly have a lot on their plate during a shift. Whether it is doing assessments,

giving medications, giving treatments, charting, or communicating with doctors and families, they

always have a lot going on. One study that consisted of choosing a select group of ICU nurses to

observe over a course of four hours determined that a single nurse’s workload generally consists

of numerous tasks that were then divided into twelve different categories. The categories consisted

of medication, direct patient care, documentation, administration, observation, conversation,

assistance, teaching and learning, housekeeping, transportation, personal, and miscellaneous (Jie

et al., 2017). According to Roth, Wieck, Fountain, and Haas (2015) “Swamping or too heavy
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workload is the most important factor according to nurses” (p. 266), to cause medication errors.

The study also researched what the most common reason to cause errors was, which they found

that to be swamping, or too heavy of a workload (Roth et al., 2015). In most hospitals there are the

day shift and the night shift nurses. In a study by (Roth et al., 2015) 71% of nurses reported that

they felt more overwhelmed during their day shift compared to the night shift nurses.

As a nurse you are able to work on many different units. Depending on which unit you

work on, it can add more stress to your job. During a study that was conducted, it showed that

there was a significant relationship between the unit the nurse was working on and the number of

medication errors (Muroi et al., 2016). According to Muroi, Shen, and Angosta (2016)

“Medication errors occurred most frequently in medical-surgical units” (p.182). On a medical

surgical unit there are more patients to be taken care of, therefore, nurses have a higher chance of

getting distracted while administering medications, which can increase the chance of an error

occurring (Muroi et al., 2016). When comparing the patients contribution to workload, med errors

are affected by multiple patient factors. When a nurse has multiple patients that have higher critical

conditions, these patients usually have more medications with multiple routes of administration

which puts a massive workload on the nurse. According to Aires et al. (2016) “The workload varies

according to the inpatient complexity, clinical status, procedures and therapy used so that the more

critical the patient’s condition or, the greater the number of adverse events, the greater the burden”

(p. 4577).

Another major factor causing nurses to make medication errors are interruptions.

Interruptions are a typical part of many healthcare professional’s workday. According to Johnson

et al. (2017), A study conducted by Prakash (2017), “The causal relationship between interruption

and error has also been examined with a recent study conducted within a simulation laboratory,
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finding that nurses were more likely to make errors when interrupted compared with when they

were not interrupted” (p. 499). The main source of interruptions was nurses themselves or other

nurses (40%) (Dante et al., 2016). The secondary source of interruptions were the patients (13%),

and the interruptions were related to patients asking for help, asking questions, making comments,

or asking for assistance with ADL’s (Johnson et al., 2016). The last most frequent source of

interruption was made by medical officers (11%) and included ordering tests, asking questions,

attending patients, looking for patients charts, and discussing patients and their plan of care

(Johnson et al., 2016). According to Roth et al. (2015) “Distraction and interruptions have been

studied as human factors contributing to nursing errors. Biron et al found an average of 6.7 work

interruptions per hour during medication administration” (p.264). Interruptions are something that

occur frequently and cause clinical error, procedural failure, and affect patient safety.

A surprising factor that was presented in one of the studies was the relationship of

medication errors to nurses impaired by a substance. According to Roth et al. (2015), “The factor

identified by the nurses as most likely to cause an error was a nurse impaired by a substance”

(p.265). This meant that if there would be an error in the hospital that nurses believed it was caused

because the nurse was impaired. Nurses impaired by a substance also scored highest for

intervenable cause of hospital errors (Roth et al., 2015). The study showed that “This factor has

the highest mean, as nurses working as staff are the most likely to identify the impaired nurse but

may be unwilling to report the suspicions” says Roth et al. (2016, p.265). Nurses being impaired

by a substance can lead to dangerous situations involving both the nurse and the patient and can

lead to medication errors that could have been prevented. It is because of situations like this that a

reporting system is in place. This system reveals any obvious causes of the medication errors so
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that preventative measures can be put in place to improve patient safety and the quality of care in

the hospital (Luk, Ng, Ko, & Ung, 2008).

Factors Related to Medications

When giving medication to a patient a nurse must know the important parts of

administration, including routes and dosages. Through research by Bolandianbafghi et al. (2017)

the average number of injectable medication errors is more commonly found than the average

number of non-injectable medication errors. In another study, according to Aires et al. (2016) ”it

can be verified that most of the participating nurses have experienced some medication error in

their work unit, with dose errors being the most frequent and the route errors the less frequent” (p.

4578).

In the hospital patients can be on a countless number of medications, each a different type.

Nurses need to know the important information regarding the medications and how they affect the

patient. In one study, according to Muroi et al. (2016) “A high number of medication errors are

found with drug classes such as cardiovascular medications, antimicrobials, and electrolytes”

(p.183). This study showed that cardiovascular drugs were reported the highest class that was

associated with medication errors (Muroi et al., 2016). Muroi et al. (2016) suggests that “ Heparin,

enoxaparin, and warfarin are among the most common cardiovascular drugs associated with MEs”

(p.183). This could be due to the fact that dosing can be complex because of laboratory values that

must be obtained (Muroi et al., 2016).

The prescriber of medications also often has a lot to do with common errors since they are

the one ordering the medication. According to Hutton, Ding and Wellman, (2017) “Computerized

physician order entry and electronic prescribing mitigate errors that occur through misinterpreted

physician’s orders” (p. 1). The new 21st century way of prescribing medications is helping to
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lessen the amount of errors by avoiding the illegible handwritten orders from physicians with the

typical “Doctor’s” handwriting. According to the Jones (2009) “The NPSA (2007) reported that

the most common type of errors are those involving incorrect dosage, strength or frequency. These

accounted for 28.2% of all reported errors and it is crucial that they are addressed because they

often result in the most severe harm” (p. 41). Dosages are also calculated by prescribers. According

to Jones (2009) “errors occurring at this stage could account for some of the above figure” (p. 41).

Although this may hold true, Jones (2009) found that “The Nursing and Midwifery Council (NMC)

states that nurses who administer drugs are responsible to know the usual dose for a drug and

should check this before administration” (p. 41). Nurses’ poor calculation ability is a major cause

of medication errors that is identified consistently (Jones 2009).

To add to being knowledgeable in drug calculations, nurses are given a protocol that they

are required to follow called the “five rights.” This include right patient, right medication, right

dose, right route, and right time. The use of the five rights is a form of medication protocols that

are now being established in order to reduce the amount of administration errors and prevent

potential additional medical issues in response to the administration error. According to Jones

(2009) “These are the final checks that should be performed by nurses administering medication

to prevent errors occurring and are standards outlined by the professional body and the law” (p.42).

One protocol commonly forgotten, is confirming the patients’ identity by comparing the patients’

identification wristband to the electronic charting and medication order . According to Jones

(2009) “In a survey in the United States of 775 readers of a popular nursing journal (74% (n=574)

of whom were hospital nurses), only 57% (n=442) of respondents said that they always confirm a

patient’s identity by checking his or her wristband” (p. 43).

Reducing the Effects on Medication Errors

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According to the research done by McMahon (2017), “ Work interruptions create danger

at the bedside, particularly during medication administration. A work interruption can be as simple

as a telephone call, noise, or an invitation to conversation by a member of the health care team,

patient or family member while the nurse is preparing medications” (p. 374). Many factors can

cause errors during medication administration and over the years there has been a lot research done

to prevent medication errors. With further research and the implementation of better policies,

hospitals have developed ways to reduce the factors that affect medication errors, which reduces

the number of medication errors overall. According to Roth et al. (2015) “Attempts to control for

the human factors involved in errors begin with measures as simple as policies and procedures”

(p. 263). To help with the knowledge of medications it would help to provide nurses with

pharmacological knowledge for safe medication administration and mandating continuing

education focusing on pharmacology (Muroi et al., 2016). Multiple ideas were included to reduce

the number of medication errors including protocol-based care plan, as well as the use of

technologies, computerization in nursing, electronic prescriptions, systems for calculating doses,

dilution and reconstitution volumes, med interactions, records for patients to see contraindications

and drug allergies, barcodes for medications and modern infusion pumps generate more safety for

the professional and the patient, minimizing the occurrence of errors (Souza, 4577).

In regards to communication between healthcare professionals and the lack of knowledge

of protocols for the safe practice in administering medications, it is emphasized that

communication and the adoption of protocols need to be integrated for the safe practice in med

administration to decrease the amount of med errors and to provide pt safety (Souza, 4578).

According to Jones (2009) a study conducted by Fry and Dacey’s (2007) analyzed 138 nurses

about what they believed would be a good solution to reduce medication administration errors.
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The Survey included a question that examined whether the use of designated and protected drug

times would be useful. Jones (2009) states that Fry and Dacey (2007) found that “only 12% (n=16)

of the respondents said that this would help them feel safer in administering medications” (p. 44).

Jones (2009) also stated that roughly “half (n=23) of these respondents who had been involved in

an incident (n=45) thought that the protected drug times would help reduce the incidents” (p. 44).

When researching the protected drug times, Jones (2009) also included research that evaluated the

effectiveness of ‘do not disturb’ signs and how applying these to areas where nurses were passing

medication would help to reducing distractions during medication administration. Jones (2009)

states that results concluded that the overall average for the extent of distractions they may

experience was significantly lower when nurses used the signs . Also, Jones (2009) states that

“medication rounds were completed more quickly when distractions were reduced” (p. 44).

Distractions, such as those from other staff members, indicated that communication through these

signs aided the awareness of not being distracted during the ongoing process of passing medication

(Jones 2009). Over the years, hospitals have begun to make barcodes on patients wristbands which

also help to lessen the amount of medication errors. According to Hutton et al. (2017), “At the

point of medication administration, a patient’s wristband and the medications to be administered

are scanned for the appropriate identification, providing integration with the hospital’s electronic

health record. This ensures that the correct patient is receiving the appropriate medication at the

right time” (p. 1). Over the past few years the amount of hospitals using bar code systems has risen

drastically. As shown by the research by Hutton et al. (2017), “ The American Society of Health-

System Pharmacists national survey found that bar code administration (BCMA) adoptions in U.S.

health systems have risen dramatically in recent years, from 1.5% in 2002 to 25% in 2008 and

more than 88% in 2014” (p. 1). With the increase of the hospitals using barcodes to identify
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patients for medication passses there was also a decrease shown in research done in a level 1

trauma center/ emergency room where a total of 1,978 medications were given (Hutton et al.,

2017). According to one of the studies Hutton et al. (2017), “Medication administration errors

were reduced from 6.3% pre-BCMA to 1.2% post-BCMA, with a relative rate reduction of 80.7%

( P < 0.0001). Wrong dose errors decreased by 90.4% (P< 0.0001). There was no significant

difference in wrong drug (P=0.5), wrong route errors (P=0.58), and unauthorized medication

administration (P= 0.057)” (p. 3). There were multiple research studies that showed similar results

which shows that bar code medication administration is effective.

With the new technology, there is also the ability to make sure that patients receive the

exact amount of intravenous fluids they are supposed to receive and ways to keep medications out

of reach of those who may abuse them. Hutton et al. (2017) research showed that, “Smart pumps

are programmed to double check dose and infusion rate and warn personnel of unsafe settings.

Automated dispensing cabinets (ADCs) have been found to reduce the amount of time that nurses

spend administering medication and may be useful in reducing error in administration time and

dose omissions” (p. 1). With the smart pumps and ADCs, the nurses can focus to making sure

there is less medication errors with the time they would spend searching for all the medications

and figuring out the exact drip rate for a patient. Technology has been advancing greatly to help

prevent medication errors and there are many factors that facilities are implementing to help

decrease the amount of medication errors.

Conclusion

In the research it was found that factors such as, workload, hospital units, patient to nurse

ratio, and interruptions contributed to more medication errors. Adding too much stress to the nurse

can cause he or she to not work as effectively and to be more susceptible to making errors.
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Medications itself are a big contributing factor to the number of errors. It is important that nurses

know the drugs they are administering and how to administer them. The research showed that in

this category the nurse is not always the one to blame because nurses need to make sure that they

have clear orders from the prescriber. It is important to find ways to reduce the number of

medication errors that can occur. Research has shown that better teaching, better communication,

less distractions, and new technology can help reduce the number of medication errors.

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