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Nurse Perceptions of
Medication Errors
What We Need to Know
for Patient Safety
Ann M. Mayo, DNSc, RN; Denise Duncan, RN
This study describes nurse perceptions about medication errors. Findings reveal that there are differences in the perceptions of nurses about the causes and reporting of medication errors. Causes
include illegible physician handwriting and distracted, tired, and exhausted nurses. Only 45.6% of
the 983 nurses believed that all drug errors are reported, and reasons for not reporting include
fear of manager and peer reactions. The study findings can be used in programs designed to promote medication error recognition and reduce or eliminate barriers to reporting. Key words:
medication errors, nursing, patient safety, reporting
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patient. Nurses may feel upset, guilty, and terrified about making a medication error. In
addition, they can experience a loss of confidence in their clinical practice abilities. Finally, they can feel anger at themselves as well
as the system.10
No studies have demonstrated strong relationships between nurse characteristics (ie,
age, years of practice, and education) and
number of medication errors.11,12 This would
seem to indicate that any nurse is potentially
at risk for making a medication error.
REPORTING MEDICATION ERRORS
Whether the nurse is the source of an error,
a contributor, or an observer, organizations
rely on nurses as front-line staff to recognize
and report medication errors. Several studies have demonstrated underreporting among
nurses.10,1215 Adding to the burden of reporting, more than 90% of the self-reports are
paper-based in California.16
Prevention of medication errors is linked
to accurate reporting of medication errors.
Reporting medication errors is dependent on
individual nurses decision making.15 Underreporting or not reporting medication errors
conceals flawed systems.1
Currently, self-reported medication errors
provide minimal information to organizations
because discrepancies, in terms of reportedto-actual rates, are widespread. Medication
errors are typically reported through institutional reporting systems such as incident
reports.15 Moore, however, estimated that organizations relying on incident reports to provide data miss up to 95% of the medication
errors.17 Reports are generated by the nurse
who identifies the error and then are forwarded to management, quality departments,
or risk management departments. Reporting
systems are dependent on the nurses (1)
ability to recognize an error has occurred,
(2) belief that the error warrants reporting,
(3) belief that she/he has committed the error, and (4) willingness to overcome the embarrassment and fear of retaliation for having committed a medication administration
error.13
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Instrument
The Modified Gladstone12 was chosen to
collect data for this study. This instrument
measured (1) nurse perceived causes of medication errors (10 items); (2) percentage
of drug errors reported to nurse managers
(1 item); (3) types of incidents that would
be classified as (a) medication errors, (b) reportable to physicians, or (c) reportable using an incident report (6 items); and (4)
nurse views about reporting medication errors (6 items). For the purpose of this study,
one additional item was added to types of
incidents that reflected a therapeutic drug
level medication scenario. The last portion of
the instrument captured nurse demographic
data (11 items). Instrument content validity was determined acceptable by previous
investigators.10,12 In addition, Osborne et al
established reliability using the test-retest
method (0.78) in their sample.12
RESULTS
Nine hundred eighty-three RNs responded
to the survey, representing a 20% return
rate. Similar to nurses across the country, the
RN mean age was 44.6 years (range = 23
74 years; SD = 9.07). Nurses were primarily female (95%), had been practicing for an
average of 18.7 years (range = 145 years;
SD = 9.94), worked full time (62.7%), and
were in benefited positions (88.2%). Similar to the state of California RNs, the ethnic backgrounds of the study participants
were varied (49% white, 34% Pacific Islander,
8% Hispanic, 4% African American, and 4%
other), as was their highest level of education (11% diploma, 40% associate degree,
44% bachelors degree, 3% masters degree,
and 3% other). Nurses represented all working shifts (42% day, 18% evening, 17% night,
12% 7 AM7 PM, 8% 7 PM7 AM, and 4%
other). Medical/surgical (M/S), critical care,
and maternal child health (MCH) practice
settings were represented (Table 1). Overall, the RNs responding to this survey were
representative of nurses working in Southern
California.
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% (n)
13.5 (133)
9.7 (95)
9.4 (92)
7.9 (78)
6.1 (60)
5.8 (57)
4.8 (47)
4.5 (44)
4.2 (41)
3.5 (34)
following:
1. nurse perceived causes of medication
errors,
2. nurse evaluation of medication scenarios,
3. nurse perceptions about reporting
medication errors, and
4. relationships between nurse characteristics (demographics) and perceptions regarding medication errors.
Causes of medication errors
Table 2 portrays the ranked causes of medication errors as perceived by the participating RNs. Nurses ranked the listed causes from
1 to 10, with 1 indicating most frequent cause
and 10 indicating least frequent cause. Mean
scores were calculated for each item and are
listed in the table. The top 3 ranked (out of
10) perceived causes of drug errors were the
following: (1) MD handwriting is difficult to
read or illegible, (2) nurses are distracted, and
(3) nurses are tired and exhausted.
Medication scenario evaluation
Based on 6 quite different scenarios presented to the nurses, Table 3 represents how
Mean
SD
3.92
2.60
4.15
2.98
4.30
4.55
5.20
5.46
5.87
2.82
2.35
2.16
2.50
3.06
6.13
7.52
2.37
2.53
7.74
2.13
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Yes (n)
No (n)
21.3 (200)
57.5 (550)
24.2 (228)
78.7 (740)
42.4 (405)
75.8 (714)
69.1 (643)
76.2 (719)
79.6 (751)
30.9 (288)
23.8 (224)
20.4 (193)
95.6 (911)
92.1 (877)
93.3 (893)
4.4 (42)
7.9 (75)
6.7 (64)
55.5 (518)
62.7 (587)
48.3 (449)
44.5 (415)
37.3 (349)
51.7 (481)
26.4 (248)
30.7 (291)
20.6 (191)
73.6 (692)
69.3 (656)
79.4 (736)
8.2 (76)
55.4 (527)
11.2 (103)
91.8 (853)
44.6 (424)
88.8 (818)
nurses classified each scenario as a medication error (yes or no responses) and if they
would or would not report the situation to
a physician or complete an incident report.
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Yes (n)
No (n)
92.6 (887)
91.3 (887)
7.4 (71)
8.7 (74)
76.9 (737)
23.1 (221)
61.4 (590)
38.6 (371)
52.9 (509)
47.1 (454)
19.6 (190)
80.4 (778)
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NURSING IMPLICATIONS
Similar to other studies, no single or combination of nurse demographic characteristics
were strongly associated with nurse perceptions of medication errors or the reporting of
medication errors. Thus, all nurses in an or-
215
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REFERENCES
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3. Thomas MR, Holquist C, Phillips J. Med error reports
to FDA show a mixed bag. FDA Saf Page. 2001;
145(19):23.
4. Speier J. Speier bill aimed at eliminating medication
errors. 2000. Available at: www.sen.ca.gov/speier.
Accessed March 2, 2004.
5. Fontan J, Maneglier V, Nguyen VX, Loirat C, Brion
F. Medication errors in hospitals: computerized unit
drug dispensing systems versus ward stock distribution system. Pharm World Sci. 2003;25(3):112117.
6. Marino BL, Reinhardt K, Eichelberger EJ, Steingard
R. Prevalence of errors in a pediatric hospital medication system: implications for error proofing. Outcomes Manage Nurs Pract. 2000;4(3):129135.
7. Morris S. Whos to blame? Nursing. 1991;4(33):8.
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17. Moore JD. Getting the whole story: the way medication errors are reported affects the results. Mod
Health. December 2128, 1998:46.
18. Wolf ZR. Medication errors and nursing responsibility. Holist Nurs Pract. 1989;4(1):817.
19. Dunn D. Incident reports-correcting processes and
reducing errors. AORN Online. 2003;78(2):211
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20. JCAHO. Official Joint Commission on sentinel event
policy and procedures. Special report on sentinel
events. Jt Comm Perspect. November/December
1998:1942.
21. Roscoe JT. Fundamental Research Statistics for the
Behavioural Sciences. 2nd ed. New York: Holt Rinehart & Winston; 1975.