Reducing Medication Errors Through a Safety Culture in Nursing

Introduction

Medication errors are a serious public health problem that poses a significant threat to patient safety. They are costly from an economic, human, and social viewpoint, since all patients are potentially vulnerable to these errors. It is estimated that in the United States more than 250,000 deaths per year are attributed to medication errors (Dirik, Samur, Seren Intepeler, & Hewison, 2019). Nurses work in a fast-paced healthcare environment, which makes administering medication a high-risk nursing task. Medication errors can occur at any phase of the medication process, from prescribing, dispensing, and transcribing, to administering, monitoring, and reporting.

When a nurse makes a medication error, he or she is often emotionally traumatized, as many nurses blame themselves for the mistake, which can undermine their self-esteem and confidence. Medication errors can be caused by any member of the healthcare team, but nurses account for the majority since they execute most medical orders and spend over 40% of their time in the hospital administering medicines (Tong et al., 2017). This paper aims to offer an overview of the problem within the clinical setting and to use evidence-based research to identify solutions that can improve the situation and reduce medication errors. A plan will be developed to address the problem of medication errors, and methods of evaluation will be identified.

In our clinical setting, a computerized provider order entry system is used to specify patient prescriptions and reduce transcription errors. In the past, nurses had difficulty transcribing what the provider had written, and this was a major cause of medication errors. However, with the installation of the system, it was expected that errors would be eliminated. Sadly, this has not been the case. The current problem is mainly due to administration and medication mixing. When a nurse is attending to multiple patients and must administer medication to them at the same time, he or she may prefer to retrieve the drugs simultaneously and make only a single round. This is a time-saving strategy that reduces the time spent traveling between the medicine cabinet and the ward. The problem arises when the nurse fails to label the drugs — especially medicines in syringes, basins, and cups — and ends up administering the wrong medication to a patient. This results in adverse drug events, as the patient may react to the incorrect drug, worsening their condition.

The Problem

For our clinical setting, the main reason nurses prefer this approach when administering medication is a shortage of nursing staff. When understaffed, nurses are overworked and tend to look for ways to increase their efficiency and reduce time spent moving around the unit rather than attending to patients.

During the administration of intravenous medicines, there are many stages where an error might occur. In our setting, most errors have been due to selection errors — where the wrong drug is selected — and reconstitution errors — where the incorrect dosage is administered. Looking at these errors, one might assume they would be easy to correct, but this is not the case. The administration of the wrong medication, as described above, is tied to mixing up drugs when the nurse fails to properly label them. Reconstitution errors are caused by administering the wrong drug dose. There are standard dosages that patients should receive, and when these are not indicated in the prescription, most nurses will assume the normal dosage applies. However, there may be instances where a nurse is unfamiliar with a particular drug and no instructions are provided for its correct administration or dilution. This would result in the patient receiving a higher dosage concentration than intended.

A culture of safety is defined as one in which there is a shared commitment among employees and management to ensure the safety of the work environment. A safe culture is one where everyone is committed to preventing, identifying, and mitigating medical errors (Cho, Heo, & Moon, 2016). It is the responsibility of everyone to create and maintain a culture of safety. Various nursing variables can compromise patient safety, including behavioral noncompliance, staffing shortages, knowledge deficits, systems problems, and lack of positive reinforcement when near misses are reported. Safety culture should be examined from all perspectives, since interventions will differ based on the responsibilities and roles of each nurse. Nurses should not be left to shoulder the efforts of a safety culture alone — every healthcare worker is responsible for ensuring and promoting it (Cho et al., 2016). Without a safety culture, nurses are more likely to make medical errors that could otherwise be avoided. A safety culture reinforces a work environment in which nurses remain alert and careful when administering drugs.

In a safety culture, a balance must be achieved between not blaming individuals for errors and not tolerating unsafe behavior. The focus should be on effective teamwork, where nurses and other healthcare workers can collaborate and interact openly without disparaging one another. All workers should understand that the goal of the healthcare facility is to offer high-quality care to patients, and this can only be achieved through collaboration and teamwork. The pervasive culture of blame must be eliminated if the healthcare facility is to accomplish its goal of reducing medication errors (Lee et al., 2019). With a blame culture, the focus was on identifying who was at fault so that person could be disciplined. However, this resulted in errors being hidden rather than reported. In a safety culture, the emphasis is on accountability, honesty, excellence, mutual respect, and integrity (Kelly, Harrington, Matos, Turner, & Johnson, 2016; Lee et al., 2019). A non-punitive approach encourages medication errors to be reported early, when corrective action can still be taken promptly. In a safety culture, the focus is on what went wrong, not on who caused the problem. With this approach, the priority is on rectifying the mistake rather than punishing the individual responsible (Kelly et al., 2016). This results in an open workplace where employees are willing to admit their mistakes and corrective action can be taken.

Background and Literature Review

Given the already existing system in place, the current project would involve training nurses and other healthcare workers on a culture of safety. In the initial stage, resistance is anticipated, as people naturally fear change. To overcome this, employees will be shown the advantages they stand to gain from the new culture. Based on Lewin's change model, this is the unfreezing step. Change champions should be identified to communicate the reason for the change and, using concrete information, to demonstrate how the change will benefit all stakeholders involved. The change should be framed as beneficial not only to the organization, but to the employees as well.

The second stage is the changing step, during which the change is implemented. In this case, that involves training employees on how to reduce medication errors and the strategies they can use to ensure they administer the correct dosage or properly dilute intravenous drugs. Culture change is one of the most difficult things to achieve in an organization, but with persistence and perseverance it is possible. During the changing phase, nurses will be trained on how to interpret prescriptions from the provider order entry system. Nurses should be encouraged to ask questions when they are uncertain about a dosage or when dosage has not been specified. If a nurse is unfamiliar with a particular drug, he or she will be encouraged to seek assistance from other nurses or from the prescribing provider. Also during this phase, healthcare workers will be encouraged to report any medication errors, and they will be made aware that no punitive measures will be taken against them for self-reporting.

The last step in Lewin's model is refreezing, in which the new culture is reinforced and solidified. The new changes become the standard, and new employees will be trained within this culture from the outset. A non-punitive approach will initially encourage nurses to report medication errors early, allowing corrective action to be taken before adverse drug effects occur. The patient can then receive corrective treatment and recover more quickly. Patient care can also be improved since it becomes a team effort rather than solely the responsibility of individual nurses. Medication errors will be reported, and with a focus on what went wrong, changes can be recommended to rectify the problem — a far better outcome than blaming a single individual while leaving the underlying issue unaddressed. The safety culture will require nurses to always label drugs in the supply area, reducing the chance of administering the wrong prescription. Collaboration will also help eliminate the problem of double dosing or missed doses. Nurses will communicate with and alert the incoming nurse during shift changes about which patients have and have not yet received their medications. This will ensure that the incoming nurse knows which patients still need medication and can administer it in a timely manner.

Conclusion

Tong, E. Y., Roman, C. P., Mitra, B., Yip, G. S., Gibbs, H., Newnham, H. H., . . . Dooley, M. J. (2017). Reducing medication errors in hospital discharge summaries: A randomised controlled trial. Medical Journal of Australia, 206(1), 36–39.