Medication errors: causes, prevention, and patient safety

¶ … Stetina, Pamela Michael Groves, & Leslie Pafford. (2005, Jun). "Managing medication errors -- a qualitative study." MEDSURG Nursing. 14. 3: 174-178.

While most people go to the hospital assuming that the care they receive will help them recover their health, Pamela Stetina, Michael Groves, and Leslie Pafford reveal in their article "Managing medication errors: a qualitative study" that an estimated 44,000 to 98,000 people die in hospitals annually because of preventable medical errors, at a rate that has steadily increased since 1983. One of the primary reasons for this is an increasingly error-prone and computer-automated medication delivery process. The process has grown more complex over the years, which increases the chances that errors may occur. Also, fewer and fewer humans are checking for vitally important components of the treatment process, like patient allergies and interactions, and nurses are left at the mercy of bureaucratic and automated system. From a managerial perspective, punitive sanctions for errors that can occur during the prescription, transcription, dispensing, or administration steps discourage nurses' voluntary self-reporting (Stetina, Groves & Pafford 2005:1).

Previous studies suggested that the top three causes of medication errors were failure to check the patient identification band with the prescription, nurse fatigue and illegible doctor handwriting. Another study suggested that nurses did not identify what most would call a medication error, such as giving medicine late. It was "discovered that nurses believed it was not an error if the nurse could correct the situation safely, if the patient status required a change, or in emergency situations" it did not 'count' as an error if the medication was given late (Stetina, Groves & Pafford 2005:1).

The authors embarked upon a new phenomenological study of nurses working in wide variety of clinical settings and levels and types of experience reporting (Stetina, Groves & Pafford 2005:3). Flexible medication times were the norm amongst these nurses. Even experienced nurses felt that late medications were not critical during busy times, stressing the need to prioritize when giving care (Stetina, Groves & Pafford 2005:4). Nursing judgment was another justification for flexible medication time, as noted by one "relatively new labor and delivery nurse" who described two situations arising on a specialty unit. The first situation related to purposely omitting a drug because of possible harm to the patient: 'Like with Pitocin[R] we have an (pause) orders to increase it by so much every 20 minutes, but if the baby's not tolerating it, we don't do it. And that's nursing judgment [not an error]" (Stetina, Groves & Pafford 2005:4). A perhaps more candid experienced ER nurse admitted that the risk of error increases when emergences occur" as a fact of hospital life (Stetina, Groves & Pafford 2005:4).