Ethical Dilemmas in Nursing Medication Error Reporting

Introduction: Medication Errors and Ethical Responsibility

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 healthcare settings today. The impact of these medication errors is severe and even life-threatening, and the potential for an increase in their frequency has been compounded in recent years as the ongoing COVID-19 pandemic has continued to stretch medical resources and healthcare personnel to their limits. When medication errors are discovered, some type of patient incident report is typically required by appropriate authorities, and the consequences of these adverse drug events can also be severe for the nursing personnel responsible (Escrivá Gracia et al., 2019).

Against this backdrop, it is clear that there are profound ethical dilemmas involved in responding to nursing medication errors. This paper provides a review of the literature to identify the ethical dilemma and how it affects nursing practice. In addition, it discusses the main moral issues raised in these situations and the relevant bioethical principles as they relate to the ethical dilemma, followed by the author's personal views grounded in personal, group, and societal moralities. Finally, the paper describes that value's relationship with the morality of a group or society before summarizing the research and key findings in the conclusion.

Scope and Impact of Medication Errors

Given the enormous number and wide array of drugs administered to Americans each year, it is little wonder that human 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 below) are harmed as a result of medication errors each year, and the economic costs of these errors exceed $21 billion. In addition, the various 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 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 has been exacerbated by the growing number of prescription medicines that Americans take each year, as well as by the devastating effects of the COVID-19 pandemic, which has filled ICU beds across the country. Taken together, nurses on the frontlines of patient care are confronted with a daunting enterprise in providing the highest quality care possible, including decisions about whether to report medication errors caused by other nurses — and the ethical dilemmas posed by those decisions are discussed below.

The Ethical Dilemma: To Report or Not to Report

Medication errors are likely seriously underreported due to the dilemma of the responsible nurse being "written up," with such reports potentially leading to 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 and by whoever discovered the error. 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!'" (p. 2)

In other words, because patient incident reporting about medication errors can have career-altering implications, many nurses likely have second thoughts about reporting 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, especially over the long term. It is noteworthy that the study by Sorrell (2017) also found that despite the widespread view that the threat of litigation represents yet another moral dilemma in deciding whether to report, this has not been borne out by the research to date. 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 stitches," meaning that nurses considering whether to report minor or otherwise insignificant and likely harmless medication errors — such as giving a patient an ibuprofen five or ten minutes early or late — may feel they will become the focus of increased scrutiny by peers watching closely for any missteps in the future. Similarly, some nurses may be tempted to overlook a minor medication error that causes no harm, with the expectation that other nurses will disregard any minor errors they may make in return. Finally, there is the potential for nurses to report medication errors made by colleagues with whom they have an ongoing feud, out of spite or revenge, while allowing nurses with whom they are friendly to go unreported.

Conclusion

The research was consistent in showing that the medication error reporting process is frequently fraught with ethical dilemmas that defy easy resolution. Like many other complex problems, these ethical dilemmas were shown to exist along a continuum that serves as a de facto framework used by nurses to guide their decisions concerning whether to report medication errors or not. Many nurses view harmless medication errors as "no big deal" and not requiring a report, due in large part to the adverse career effects that reporting can carry. Fortunately, beyond the relevant bioethical principles that can be used to guide this process, individual moral values can also help nurses make the right ethical decision despite the complexity of the issues involved.

References

Brady, A.-M., Malone, A.-M., & Fleming, S. (2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of Nursing Management, 17(6), 679–697.

da Silva, B. A., & Krishnamurthy, M. (2018). The alarming reality of medication error: a patient case and review of Pennsylvania and national data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 10–15.

Erlen, J. A. (2011). Medication errors: ethical implications. Orthopedic Nursing, 20(4), 82–85.

Escrivá Gracia, J., Brage Serrano, R., & Fernández Garrido, J. (2019). Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC Health Services Research, 19(1), 640.

Medication safety. (2021). U.S. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/medicationsafety/basics.html.

Pedley, L. (2002). Medication errors and ethical nursing practice. Perspectives, 26(2), 10–13.

Perm, J. (2018). Evidence-based medicine and bioethics: implications for health care organizations, clinicians, and patients. The Permanente Journal, 22, 1–10.

Sorrell, J. M. (2017, March 7). Ethics: ethical issues with medical errors: shaping a culture of safety in healthcare. OJIN: The Online Journal of Issues in Nursing, 22(2), 1–7.