The Complex Nature of the Ethics Involved in Reporting Nursing Medication Errors

Ethical Dilemmas in Responding to Nursing Medication Errors

It is well documented that medication errors made by nurses are among the most prevalent but also the most preventable types of adverse patient incidents that occur in health care settings today. The impact of these medication errors is also severe and even life-threatening, and the potential for an increase in the numbers and frequencies of medication errors has been compounded in recent months as the ongoing Covid-19 pandemic continues to stretch medical resources and health care personnel to their limits. When medication errors are discovered, though, some type of patient incident report is typically required to be made to appropriate authorities and the consequences of these adverse drug events can also be severe for the nursing personnel who are responsible (Escriva et al., 2021). Against this backdrop, it is clear that there are some profound ethical dilemmas involved in responding to nursing medication errors. The purpose of this paper is to provide a review of the literature to identify the ethical dilemma and how it affects nursing practice at present. In addition, a discussion concerning the main moral issues that are raised in these situations and relevant bioethical principles as they relate to the ethical dilemma is followed by the author’s personal views about this which are based on personal, group, and societal moralities. Finally, a description of that value’s relationship with the morality of a group or society with which the author is currently living is followed by a summary of the research and important findings in the conclusion.

Review and Discussion

Given the enormous numbers of the wide array of drugs that are administered to Americans in different ways each year, it is little wonder that huma errors occur from time to time, but the implications of these errors can be profoundly severe and even life-threatening. The most recent estimates indicate that more than 7 million people (perhaps even more due to unreported cases as discussed further below) are harmed as a result of medication errors each year, and the economic costs of these errors exceeds $21 billion. In addition, the various types of adverse effects of medication errors add between 1.7 and 4.6 patient days to inpatient care each year (da Silva & Krishnamurthy, 2018).

The adverse drug effects that are caused by medication errors include 1) allergic reactions, 2) a wide range of other side effects, and 3) the overmedication of patients (Medication safety, 2021). Furthermore, the potential for these and other types of adverse effects from medication errors has been exacerbated by the growing numbers of prescription medicines that American take each as well as the devastating effects from the ongoing Covid-19 pandemic which has completely filled ICU beds across the country in recent months. Taken together, nurses who are on the frontlines of patient care are confronted with a daunting enterprise in providing the highest quality care possible, including the decisions as to whether to report medication errors that are caused by other nurses and the ethical dilemmas posed by these decisions are discussed further below

What is the ethical dilemma? How does the dilemma affect nursing?

Medication errors are likely seriously underreported due to the dilemma of the responsible nurse being "written up” and these reports could potentially lead to their termination. It is reasonable to posit that the vast majority of unreported medication errors did not cause any substantive harm to patients and the decision to overlook these incidents can easily be rationalized by both the nurse responsible as well as whomever discovered it as well. For instance, according to a study by Sorrell (2017):

Nurses working in long-term care noted that participants had different definitions of what constitutes harm with a medical error; their perceptions of harm influenced whether they reported the error. Because of busy working conditions, these nurses prioritized which errors to report. One participant stated, ‘If it’s caused no harm, it’s no big deal!’” (emphasis added) (p. 2)

In other words, because patient incident reporting about medication errors can have career-altering implications, many nurses likely have second thoughts concerning whether to report medication errors that did no perceptible harm to patients (Pedley, 2002).

Notwithstanding their professional training and experience, however, it is also reasonable to posit that it is extremely difficult or even impossible to determine with complete accuracy whether a given medication error harmed a patient or not, especially over the long term. It is noteworthy, though, that the study by Sorrell (2017) also found that despite the widespread view that the potential for nurses and their health care organizations being sued for medication errors represents yet another moral dilemma when making the decision to report or not, this has not been the case with the research to date. For instance, according to one of the more salient findings by Sorrell (2017), “Nurses in all settings need education and training to develop a shared definition of harm and understand the process for reporting errors. Although fear of litigation is often cited as a barrier to disclosure by healthcare providers, there is no established link between willingness to disclose medical errors and the risk of litigation” (p. 4).

Yet another moral dilemma is associated with the adage, “snitches get stiches,” meaning that nurses who are considering whether to report minor or otherwise-insignificant and likely harmless medication errors (i.e., giving a patient an ibuprofen 5 or 10 minutes early or late) or not may well feel that they will become the focus of increased scrutiny by their peers who will be watching closely for any missteps on their part in the future. Similarly, some nurses may be tempted to overlook a minor medication error that does no harm with the expectation that other nurses may also disregard any minor medication errors they may make in the future in exchange for this free pass. Finally, the potential exists for nurses to report medication errors that are made by other nurses with whom they have an ongoing quarrel or interpersonal feud out of spite or revenge while allowing other nurses with whom they are friends to go unreported.

What are the main moral issues raised in the situation?

In this context, patient harm exists along a continuum ranging from absolutely no harm to death, so determining whether to report a medication error or not despite legal and organizational protocols that require them to be formally reported represents a major moral issue for the many of the reasons discussed above. In brief, these main moral issues include 1) deciding whether to report a seemingly harmless medication error, knowing that the implications for the nurse who is responsible may be severe – especially if it is among numerous others that have been reported in the past; 2) reporting or not reporting medication errors based on personal feelings towards the offending nurse or even the patient that was involved; and 3) failing to report medication errors based on the expectation that other nurses will reciprocate at some point in the future. Despite the complexity of these and other moral issues that are involved in deciding whether to report medication errors or not, there are some general bioethical principles that can be used to guide the decision-making process as discussed below.

Two bioethical principles as they relate to the ethical dilemma

Over the past several decades, four basic principles have been formulated in an effort to better understand Western bioethics. These four principles are 1) respect for autonomy, 2) beneficence, 3) nonmaleficence, and 4) justice which are operationalized as follows:

· Autonomy: This principle entails respecting the right of another individual to determine that person’s own course;

· Beneficence: This principle entails promoting the well-being of others;

· Nonmaleficence: This principle represents the intention to avoid harming or injuring others; and,

· Justice is the fair, equitable, and appropriate treatment in light is what is due or owed to other people and, conversely, injustice involves a wrongful act or omission that denies people resources or protections to which they have a right (Perm, 2018, pp. 1-2).

Although each of these foregoing bioethical principles is relevant to the ethical dilemmas described above at varying levels, nonmaleficence and justice appear to be paramount in the context of medication error reporting. While most nurses likely internalize all of these bioethical principles as part of their quest to become the best clinician possible, people are just people and may attempt to get away with whatever they can under different circumstances. Therefore, personal moral values also represent an important element in the decision whether to report medication errors or not and this issue is discussed below.

Based on personal, group, and societal moralities, identifies a value of your own personal morality

An important value that is based on this author’s personal morality is that patients trust their health care providers to “first do them no harm,” so any violation of this trust can create long-term constraints to establishing the therapeutic rapport that is an integral part of achieving optimal clinical outcomes (Brady, Malone & Fleming, 2009). This violation of trust can also adversely affect patients’ future encounters with health care providers which can even be based on a single, isolated episode. Given the trust that is instilled in professional nurses by the vast majority of patients in the United States, this personal value is particularly relevant for the purposes of this discussion as it relates to the larger American society as noted below.

Describe that value’s relationship with the morality of a group or society you are currently living

America society in general places a high priority on consumers being able to absolutely trust certain occupations such as law enforcement authorities, first responders, firefighters and even lawyers to consistently perform their jobs in ways that protect them from harm. Indeed, scarcely a day goes by without headlines reporting yet another high-profile instance of this trust being violated by people in these and similarly situated occupations, and the cumulative effect of these violations can likewise have dire consequences for Americans who may learn to distrust the very people whom they need to help them during emergent situations. When it comes to trusting health care professionals to do the right thing even when something wrong was done is therefore an integral part of the morality calculus when it comes to the decision-making process for reporting or not reporting medication errors (Erlen, 2011).