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Giuliana Davanzo, Ashley Fagert, Alesha Fulton, Olivia Gerke, and Sydny Paul
04/02/2018
Spring 2018
Abstract
FACTORS CONTRIBUTING TO MEDICATION ERRORS
1
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
Medication errors are one of the most talked about situations in nursing. No registered
FACTORS CONTRIBUTING TO MEDICATION ERRORS
2
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
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, specifically MEDLINE, OVID, and CINAHL Plus. Ten sources were used
FACTORS CONTRIBUTING TO MEDICATION ERRORS
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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,
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
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
personal, and miscellaneous (Jie et al., 2017). According to Roth, Wieck, Fountain, and Haas
(2015) “Swamping or too heavy workload is the most important factor according to nurses” (p.
FACTORS CONTRIBUTING TO MEDICATION ERRORS
4
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
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)
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
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
FACTORS CONTRIBUTING TO MEDICATION ERRORS
5
laboratory, 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
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
FACTORS CONTRIBUTING TO MEDICATION ERRORS
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that preventative measures can be put in place to improve patient safety and the quality of care in
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).
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
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
FACTORS CONTRIBUTING TO MEDICATION ERRORS
7
medications is helping to 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
According to the research done by McMahon (2017), “ Work interruptions create danger
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).
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).
FACTORS CONTRIBUTING TO MEDICATION ERRORS
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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.
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
FACTORS CONTRIBUTING TO MEDICATION ERRORS
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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 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
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
Conclusion
FACTORS CONTRIBUTING TO MEDICATION ERRORS
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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.
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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