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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).

A medical-surgical nurse provided a different perspective, saying that her hospital's methodology of double-checking charts was helpful in preventing errors. However, reliance upon hospital-imposed assistive system, including medication administration records (MARs) and automated medication dispensing machines (AMDMs) can also increase the risk of errors, if patient allergies and drug interactions are not recorded in the system. In addition to variance from standard practices, "nurses showed an increased reliance upon computerized and systematic checks put into place in health care systems. Nurses viewed the systems as infallible and as a relief from the duty of systematic checking against error" (Stetina, Groves & Pafford 2005:4). However, the author's studies express considerable concern about the nurses' willingness to suspend their own judgment and leave themselves and their patients at the mercy of automated systems, as well as the nurses' lack of concern about correct dosage times when busy or fatigued.