The Best Nursing Strategies to Minimise Drug Administration Errors - Literature review Example

The Best Nursing Strategies to Minimise Drug Administration Errors Customer Inserts His/Her Name Customer Inserts Grade Course Customer Inserts Tutor’s Name 03, 09, 2010 Outline. Abstract Introduction Types and Nature of Errors Causes and factors that contribute to drug errors Strategies to minimize drug administration error Future Recommendation Summary Abstract There are several strategies that are aimed at minimizing drug administration errors in nursing practice. This paper will examine several literatures that are available on this subject and thereafter offer recommendation on the practices that it finds to be future oriented. This review has been necessitated by findings by Australian Commission on Safety and Quality in Health Care that places the number of people suffering from drug effects at 1.5 Million with 140, 000 of this occurring due to hospitalization (Roughead & Semple, 2009). It is important to examine the best strategies that have been documented by various researches in order to identify what is workable in our clinical setting. This paper will review several studies with specific objective of discovering the best nursing strategies to minimize drug administration errors. Introduction Healthcare providers across the world are concerned with medication errors which have been highlighted by several researches to be critical in healthcare provision. Medication involves several procedures which brings together different parties; nurses, pharmacist, and physicians among others. Nurses however are responsible for overall administration of medication. Many researches recognize that administering wrong medication can have devastating effects not only on the patient but also the person administering the drug. Nurses encounter numerous risks during administration of medications (Anderson & Webster, 2001). Numerous errors have been identified by various researches and their possible causes. Banner et al (2001) indentified some of the errors as; wrong time medication, missed dosages, wrong rate either administering a drug too quickly or too slow and wrong quantity of drugs administered among others. According to Santell (2005), the causes of drug medication errors can be broadly classified into human and environmentally caused errors. Human causes include, stress fatigue, knowledge deficit, dose miscalculation, skill deficit and intimidating behaviour while environmental causes are interruption and distraction, poor communication, staffing, inexperience, lighting, noise and training. Anderson & Webster (2001) recommends the use of system approach in developing strategies to reduce medication errors. Their arguments are founded on Reason et al (2000) argument that medication is process born out of collaborative efforts of various aspects that should be improved as a whole to reduce the error rather taking the ‘person centered approach’. Types and nature of errors In a study carried out on nursing errors in the United States, Banner et al (2001) examined 21 case studies picked out of the disciplinary files presented to the States Boards of Nursing and categorized nursing errors into eight broad categories. Under these categories, drug administration errors were classified as one of the nursing errors. Benner et al (2001) identified the following as the most common types of drug administration errors; Wrong timing Missed dose Wrong rate i.e. too slow or too fast Overdose Under dose Wrong strength Wrong dose and ; Extra dose These findings are confirmed by similar studies carried out by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). NCCMERP designed a Medical Error Questionnaire (MEQ) which was administered to nursing practitioners in Victoria. A sample of 154 registered nurses was picked. Out of the total respondents, administration of drugs at the wrong time was the highest type of error with 31 %, followed by missed dose at 16 %. Other types of errors were below 4%. According to statistics available on Santell et al (2005), errors of omission, underdose/overdose errors, and improper prescription errors constituted 68% of the errors reported. Santell et al (2005) also found the most commonly committed errors that caused harm to the patient were; wrong route of administration, wrong administration technique and administering wrong quantities of the drug dose. The errors listed above have been categorized by most of the reviews into two broad categories i.e. errors during drug preparation stage and errors during drug administration stage. As stated by Wright (2008), comparative study of the errors and their causes is difficult because most studies varied on whether to collate or separate the errors into these categories. Part of this dilemma is caused by different definitions of drug errors. Taxis & Barber (2003) defines drug error as ‘any medication that during administration or preparation deviates from manufacturers or hospital guidelines’. Taxis & Barber (2003) however concludes that most errors occurred mainly with drugs that needed multiple preparations especially those that need solvents. Cousins et al (2005), Wirtz et al (2003) & Han et al (2005) identified that errors of wrong dosage occurred mainly on IV drugs, while error of wrong rate occurred for bolus dosages being given too quickly or two slowly. Wirtz et al (2003) also identified compatibility error where two or more drugs are administered at the same time. Causes and factors that contribute to drug error One leading cause of errors as outlined by Santell et al (2005) is failure by medical practitioners to adhere to what they were trained or educated on. Santell describes this as performance deficit. It was cited together with other factors i.e. distraction and staff shortages. NCCMERP classifies causes of drug errors into two; human causes and environmental causes. Under the human causes, stress fatigue, knowledge deficit, dose miscalculation, skill deficit and intimidating behaviour were ranked as the most common to the least common causes respectively. The MEQ (Medical Error Questionnaire) administered by NCCMERP placed interruption and distraction as the leading cause of errors among medical practitioners. The other environmental causes of medical errors are poor communication, staffing, inexperience, lighting, noise and training ranked from the most frequent cause to the list frequent cause respectively. According to a publication in the Journal of Advanced Nursing, Andersons & Webster (2001) stated that advances in medical technology is increasingly making nurses’ working environment to be complex. They also pointed out that a lot of literatures and investigations on nursing errors are inclined on investigating the nurse; an approached described as ‘the person centered approach’ (Reasons, 2000). Reasons a psychologist, describes this approach as one founded on a belief that a nurse causes errors because of lack of motivation, forgetfulness, negligence, recklessness among others. Reasons however argue that a better approach would be to look at the system rather than the person (Anderson & Webster, 2001). The system approach argues that an accident is caused by interaction of several factors of which ‘the person’ is part of. In this argument, it is important to note that no individual agent will be identified as the primary cause. The system as a whole may contribute to overall failure in administration of drugs (Schroeder, 2001). The system approach is supported by several publications that try to examine the whole medication system. For example, Wright (2008) in a review published in the Nursing Education Today journal indentified various findings in the United States that support these arguments that error occur across the medication system. It reported that the errors omitted or committed by a physician, pharmacist or other practitioners were likely to be transferred by the nurses to their patients. Wright (2008) however was more interested on ascertaining whether nurses’ mathematical skills had an impact on causing errors especially during calculation of doses to be administered to a patient. Most of the studies and review before focused mainly on other factors leaving out mathematical skills. A review by O’Shea (1999) highlighted mathematical skills as one factor that contributed to medical errors. However as noted by Wright (2008), most of the studies did not actually carry-out a test on calculation skills of nurses in their clinical setting nor did the reviews examine errors attributed to lack of calculation skills in the clinical setting. Wright (2008) questions the validity of written test in measuring the calculation skills of nurses in clinical practice. Notwithstanding the risk of assuming a direct correlation between poor scores in written test and real performance in clinical practice, Wright (2008) concludes that mathematical skill contributed to errors in administering drugs as indicated in other reviews. Despite numerous literatures on drug administration errors, these errors continue to happen in the clinical setting (Anderson & Webster, 2001). This phenomenon can be explained by the ‘law of large numbers. The law recognizes that despite best efforts on minimizing drug administration errors, we cannot absolutely do away with the possibility of errors occurring. This is because the process of medication is guided by machines and human effort which are not100% error proof. The other thing is that, the safety standards are continually changing as more and more people become exposed to the potential danger of being victims of drug administration serrors (Kohn, L.T et al, 1999). Strategies to minimize drug administration error Double checking Anderson & Webster (2001) notes that; the belief that a drug error is the fault of a nurse is far too limiting. Citing previous studies on minimization of errors, Anderson & Webster did not dismiss the idea of offering nurses a check list to counter check medication. Notwithstanding their importance, Anderson & Webster stressed the need for more effective approaches like the ones adopted in the aviation industry to be integrated into the medical profession to help reduce medication errors. Armitage (2007) documented findings from several reviews which support double checking as a tool for error reduction in medication As stated earlier, medication errors are not only caused by humans (nurses), some are environmentally caused. Anderson & Webster considered the checklist as a tool that only deals with the human causes of medication errors. They cited continued rise of drug errors in the wards as a clear indication that these person- centered- approaches are not effective. Reasons (2000) suggest the concept of double checking. This concept involves one person cross checking what another medical practitioner has done to detect and possibly correct errors before administering the drugs. While acknowledging these efforts, Anderson & Webster (2001) states that checking and rechecking in the long run will reduce errors but it will not 100% error proof because of human are to err. Davis & Drogasch (1997) introduced the concept of triple checking but Anderson & Webster questions the logistics and utilization of human capital in triple checking medications before administration. Multiple checking according to Anderson and Webster (2001) is an elusive effort and diversionary from the main problem because it only lays emphasis on the nurse and not the aggregate medication procedures which urgently requires attention. This argument is supported by Armitage’s (2007) findings among several researches. Leape considered double checking as a ‘sacred cow’ that is ineffective and time consuming. The effectiveness of double checking according to Armitage (2007) is watered down due to reduced sense of individual responsibility in the process. Individuals developed laxity and did not take responsibility for their actions. Anderson & Webster (2001), stresses the need for continuous checking, testing of doses in combating medication errors. They referred to earlier studies by Cooper which promoted ‘zero defect’ philosophy in creating human-system interaction phases to limit errors. Cooper gives an example of pre-filing syringes with a dose of medication dully determine for a particular patient. The error will be limited because all what the nurse needs if to administer the drug the way it is. For this system to be effective however, routine testing and calculation of drug performance should be carried out. A syringe filled some days before may have been damage or performance strength diminished (Anderson & Webster, 2001). More so, Cousins & Upton, (1999) agrees with this model. They recognized that routine testing and calculation of drug performance not only improve the safety but also increased performance efficiency for nurses. Change Attitudes to error & Reporting an error Over the years, various studies have documented the psychological trauma that medical practitioners go through when the commit medical errors (Schelbred & Nord, 2007). According to Schelbred & Nord (2007), many reviews on medication errors have focused mainly on identifying errors, possible causation factors and whoever is responsible. Therefore, the attitudes have always been that of shifting the blame from one person to another. Schelbred & Nord (2007) suggests that there should be change in attitudes when developing strategies to combat medication administration errors. They suggest a constructive approach where fundamental causes and the psychological effects it brings to nurses should be integrated together with counseling and support. When Gibson (2001) was exploring literature on medication errors, many of them documented nurses’ experiences through law & management, and biomedicine. Research outcomes documented by Schelbred & Nord (2007) showed that nurses experienced shock and disbelief on discovering that they had committed a drug error. The participants in the study however indicated that they did something after committing those errors. Most of them confirmed that they at least tried to minimize the potential disastrous effects of the drug error. All those interviewed indicated that the felt the need to report the accident to the relevant people. Majority of the nurses interviewed reported the accident and the potential consequences to the patient or to their family member who empathized with the nurses. The reaction among the colleagues and the doctors was varied. They varied from providing emotional support to assisting in minimizing harm caused by the error. A number of them felt that their colleagues considered the incompetent. This kind of response should change (Gibson, 2001). The proponents of system approach appreciate the importance of effective reporting system in implementation of system approach strategies (Anderson & Webster, 2001). However, according to various findings, the existing systems for error reporting are not sufficient and effective in dealing with medication errors. Anderson & Webster (2001) recognized that near-misses were more frequent than accidents and therefore an approach to error reporting that documents all near-misses will helpful in designing a corrective system that will reduce errors’ potential of reoccurrence. Anderson & Webster (2001) illustrates a model that has a wider focus on error reporting in the diagram below. Figure 1: A system approach model that shows how error reporting mechanism should be focused on. While appreciating the complexities of factors that cause medication errors, Anderson & Webster (2001) indicated that attitudes towards error reporting should change. They argue that when an error is reported, it should not be viewed as admitting guilt, carelessness, and incompetence. Focus should be on data collection and formulation of strategies to minimize errors. It was noted that when error reporting was taken seriously by the authorities, the frequency of error reporting increased. Schelbred & Nord (2007) suggests that a system of formal feedback and education within a setting should be introduced to encourage error reporting. Anonymous incident reporting Another element of error reporting is anonymous incident reporting. Anderson & Webster (2001) stressed the importance of anonymity in order to reduce blame which has an effect of discouraging error reporting. According to studies carried out in the US and the UK (Kohn et al, 1999 and DOH, 2000), there are numerous advantages that come with anonymous reporting. The research found out that in settings with anonymous reporting, the reporting rates were high. This confirms the assertion made by Anderson & Webster (2001). Kohn et al (1999), DOH (2000) and Anderson &Webster (2001) recognized the advantages of anonymous error reporting as cost effectiveness, legally/medically safe, universally applicable and increased volume of errors reported with specified information. These advantages concur with others documented in an earlier study by Runciman et al, (1993). Although anonymous reporting will cover exposure negligent nurses, other systems in the establishment should be able to weed out this group (Schelbred & Nord, 2007). It was also discovered that individuals who reported frequently contributed more to error reduction. Anonymous reporting encourages honesty which improves the accuracy of the data collected. Accuracy is very important in designing workable systems because the system designed will reflect whatever data was collected (Anderson & Webster, 2001). Oborne et al, (2002) in study of community participation on error reporting concerning errors committed by pharmacist, documented that anonymous reporting encouraged more feedback from the community and ensured impartiality. A feedback system that involved frequent publication of data collected on errors created more awareness among the community members and medical practitioners. This feedback system improved ownership of the process and encouraged participation (Oborne et al, 2002). According to Tissot & Woronoff-Lemsi et al, (2003), anonymous reporting has enormous potential of reducing medication errors more than any other measure. The core of error reduction strategies depend on discovering vulnerable error prone medication administration procedures, and anonymous reporting provides valuable non biased information (Tissot & Woronoff-Lemsi et al, 2003). Routine testing of dose calculation performance In a study carried out by Cecil Deans (2005), it was discovered that the nurses’ knowledge deficit was one of the factors that contributed to medication errors. In the study Cecil Deans (2005) documented that about 30% of the respondents (nurses) indicated that they needed refresher training in drug administration to improve their skills especially in drug calculation. Although a larger percentage indicated that they were confident with their medication skills, the study recorded that maybe some respondents did not want to admit incompetence (Banner et al, 2005). Whose responsibility is it therefore to make sure that nurses’ medication competence is up-to-date? Jarman et al, (2002) argues that is both the responsibility of the individual nurse and the clinical administration to develop nurses’ medication administration competence. To maintain these skills, it requires the administration to routinely test nurses’ competences to ensure that they can handle their responsibilities effectively (Jarman et al, 2002). As noted by Kohn, L.T et al, (1999), the standards of safety are continually shifting, in response to the ever changing environment and improved technology. These brings with it new challenges and opportunities. Nurses’ skills should be periodically evaluated and updated to match the current medication formulas and discoveries (Kohn, L.T et al, 1999). According to Mayo & Duncan, (2004), IV medication presents the greatest danger in drug medication errors. IV medication involves complex drug calculation on the dose and proper choice of the drug administration route. Shea, E., (1999) noted that IV drugs errors occurred by either administering a rate too quickly or rate too slowly (Taxis & Barber, 2003, 2004). The errors could be minimized if the competence of the nurses is continually monitored. There was no consensus on how regular the drug calculation skills should be tested. Many reviews considered that the clinic administration should be able to determine the competency needs of their nurses. In fact the Vitoria Nursing Board expects nurses to only administer medication in areas their competent on. Periodic evaluation allows the administrator to know which areas an individual nurse has competencies on and position him/her on those areas (Taxis & Barber, 2003). According to a literature review carried out by Wright (2008), many studies documented that majority of medication errors were cause by administering wrong dose. The studies did not identify at which stage the medication error was caused. It was impossible to know whether errors were initiated by wrong prescription by the physician or committed by the nurses when administering the drug (Selbst et al., 1999). The argument that nurses drug calculation skills at the administration stage was the sole cause of wrong dose errors could not conclusively be supported (Selbst et al., 1999) . Wright (2008) identifies with this argument and concluded that nurses’ mathematical skills should not be the only area to be periodically evaluated. Skills across all stages should be reviewed to make sure that errors committed out of mathematical incompetence at one stage are not transferred to the next stage. Education, training, and awareness programs Education and training is the key to development of nursing skills and eradicate medication errors currently being experienced in the field. Several studies have pointed out lack of skills especially mathematical skills as one of the major causes of drug errors (Hutton, 1998; Weeks et al., 2000; Wilson, 2003; Wright, 2008). These studies noted that, between 10%-20% of the errors made by nurses were due to poor drug calculation skills. The UK Department of health have shifted focus into building competencies on drug calculation skill among nurses through education and training in order to minimize drug errors (Wright, 2008). The Nursing and Midwifery Council followed suit and made competency in drug calculation a prerequisite in admission to the profession (Wright, 2008). However, according to Anderson & Webster (2001), numeracy skills among nurses do not translate directly to better drug calculation. Anderson & Webster (2001) notes that, an error of omission or commission in one part of the system will likely be transferred throughout the drug administration process. Another aspect of education highlighted by Abushaiqa & Zaran et al, (2007) is the use of abbreviations. Many medical practitioners use abbreviation in writings. According Abushaiqa & Zaran et al, (2007) these abbreviations have contributed to errors in administration of drugs because nurses translate the abbreviation differently leading to errors. Abushaiqa & Zaran et al, (2007) suggest that effort should be made to educate the not only the nurses, but also other medical practitioners including the pharmacist. As Wright (2008) points out, there is no evidence that drug calculation is a strong cause of drug errors in the profession. The study cited low percentage of incidences attributable to poor drug calculation skills among nurses. Notwithstanding its importance, drug calculation skills among nurses are not the only element of education that should looked at (Røykenes & Torill, 2001). According to Røykenes & Torill (2001), updating of general nursing skills and medication procedures is also important. Awareness of how an individual interacts with the environment should be promoted to ensure that there is a clear understanding on what part an individuals should perform or behave in a particular setting (Anderson & Webster, 2001). These awareness programs should aim at enlightening not only the nurses, but the whole systems. This includes the role of a patient in creating a conducive working environment for medical practitioners to deliver their services efficient and effectively with minimal stress (Wright, 2008). As noted earlier, awareness should include the community. A feedback system that discloses data collected will accelerate the need to minimize drug errors (Oborne et al, 2002). Future & Recommendation Medication errors among the nurses are not expected to completely disappear. From the literature reviewed above, none of the researches mentioned complete eradication of errors in the future. However, many of the authors are optimistic that their findings can offer some highlights that will assist in developing systems aimed at reducing medication errors. Crossman (2009) noted that no single strategy will be sufficient in limiting medication errors across the medical profession. This concurs with the systematic approach advanced Reason a psychologist and a system expert. Reasons (2000) recognized that there are several related factors that contribute to errors committed or omitted by nurses during drug administration. These factors are either personal factors such as stress fatigue, knowledge deficit, dose miscalculation, skill deficit and intimidating behaviour, or environmental factors such as poor communication, staffing, inexperience, lighting, noise and training. More emphasis also have been placed on error reporting and the potential benefits it has in providing critical information that is necessary in designing effective systems (Schelbred & Nord, 2007). A more effective error reporting system should guarantee anonymity. Anonymity reduces labeling and reduces the chances of being branded incompetent (Anderson &Webster, 2001). It is evident that no single approach in itself is sufficient to manage administration errors that nurse encounter in their practice. However, the system approach explained by Anderson & Webster (2001) offers a realistic way of dealing with medication errors. It provides us with opportunities to examine the medical procedures that we encounter in our clinical setting. If the systems approach is adopted in the clinical setting, it will identify potential error prone areas, encourage error reporting and reduce blame and labeling. The clinical setting has in the past over-relied on double checking in an effort to reduce errors. As noted in the review, even triple checking is not the solution (Leape & Berwick 2000). This strategy is time consuming and offers new logistical challenges of human capital capable of guaranteeing an error free drug administration. This strategy should be supported by other measures for it to work effectively. The volumes of work in the current environment renders double/triple checking strategies almost impossible to achieve. Greater individual scrutiny and personal responsibility will reduce the need for double checking. As seen in the aviation industry where double checking work magnificently, double checking will not be completely phased out in effort to reduce medication error. The systems approach that has been generally supported by various literatures includes looking at the following group components that make part of the whole system; design, equipment, procedures, operators, supplies and environment abbreviated as DEPOSE (Anderson & Webster, 2001). While trying to elaborate this approach, Anderson & Webster (2001) gave an illustration of the cycle drugs go through from design component that involves testing of the drug before introducing to the market, the equipment component that involves safety manufacturing and distribution, prescription (procedures component), the operator component that looks at how the drug is administered to the patient, the supply component that looks at how constituent the supplies are, and finally looking at the environment to ensure that it if conducive for nurses to work. The errors committed in a clinical setting can not only be attributed to the operator (Goldspiel, et al, 2000). Goldspiel, et al (2000) advocates for adopting a continuous improvement of all the parts in order to achieve greater benefits. A total systems approach to error reduction should be the main focus for professionals in this current environment that is continually changing and demanding new standards (Tissot & Woronoff-Lemsi et al, 2003) Summary Drug errors will continue to plaque the nursing profession with potentially devastating effects to both the patients’ health and the nurses’ career. It is imperative to continually reviewed factors that contribute to administration errors among the nurses in order to design workable solutions in the future. Research on medication errors comes from history of being person centered to the current non punitive approaches that try to examine the medical procedures to determine the weak chain. Several researches have concluded that medication errors are not a preserve of personal negligence, carelessness, recklessness, or incompetence. Administration of medication involves various stages but the most responsible person will be the nurses. While removing complete blame or nurses alone, most studies confirm the critical measure of responsibility that nurses have in limiting or increasing medication administration errors. Currently, most researches and reviews support the system approach advanced by psychologist Reason to be more reflective of the real situation. Systems should be built along this model which has its roots in the aviation safety industry. It is important to note that the efforts to achieve ‘zero defects’ is elusive and such an environment may never be achieved. Efforts should concentrate on building effective systems that are realistic and manageable. Read More