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Chapter 5: Drug Administration Errors

Learning objectives for this chapter

By the end of this chapter, we would like you to understand:

- What a drug administration error is

- Common causes of drug administration errors

- The responsibilities of nurses with respect to drug administration errors

- How nursing policy and practice can be shaped to reduce the risk of drug administration errors

- Strategies that can be implemented to reduce the risk to patients

- The effects of "blame culture" on the likelihood of errors occurring

What is a drug administration error?

A drug administration error is where an incorrect or inappropriate administration of a drug to a patient occurs in comparison with either the prescription or local hospital policy. This could include the wrong drug being administered, or at the wrong strength or dosage, or to the wrong patient. The consequences of these errors can range from insignificant effects to patients through to patient death. It is therefore of great importance that all medical staff work together with institution policy makers to reduce the risks posed to patients by medication errors. Drug administration errors are thought to be common, with some observational research studies suggesting that between 19% and 27% of all drug administration had some degree of error (Westbrook et al., 2010; Colen et al., 2003; Ghaleb et al., 2010).

Drug administration errors can result from active failures in medical practice or latent conditions within the organization. Active failures might include a lapse in concentration causing a nurse preparing a drug for administration to select the wrong dosage of the drug, or a lack of knowledge resulting in a drug being administered by the wrong route. Latent conditions refer to inbuilt factors within local policy and practice that result in inevitable errors occurring. For example, understaffing may result in nurses having inadequate time or provision to concentrate on drug preparation, or poor medical equipment maintenance could result in drug administration error from malfunctioning equipment.

Common Causes of Drug Administration Errors

Individual Causes

A common cause of errors is tiredness; long shifts or repeated night shift working can cause all healthcare professionals to make errors in judgement. However, it should be considered that tiredness can be the effect of institutional factors such as short staffing or procedural failure to address a lack of staff due to sickness absence. A loss of concentration resulting from tiredness or distraction on the ward could result in the nurse omitting a dose of a scheduled medication or even administering an incorrect drug or drug dosage. Working in an unfamiliar environment with unfamiliar policies and procedures can also provide the opportunity for a nurse to make an error, or errors can occur as a result of a lack of knowledge and understanding on the part of the nurse regarding a drug's action, usual route of administration or mechanism. This could either result in an error being made by the nurse themselves or prevent them from identifying a previous prescribing error.

Communication problems are also a common cause of medical and drug administration errors. For example, instructions may be poorly recorded, with unclear handwriting, or contain unfamiliar or ambiguous abbreviations rather than full drug names and dosages. Units for drug dosage can also be unclear, or the incorrect unit might be used. Addressing these issues can sometimes be difficult for nurses, as historically the imbalance of power between doctors and nurses can cause doctors to become defensive when questioned, or nurses to feel that it would be inappropriate to question the doctor. However, ultimately, nurses do have a duty to question any instructions that are unclear, or that they believe may be incorrect, as this is a valuable way of identifying prescribing errors at an early stage before the wrong drug or dosage of drug is given to the patient. It is also possible to make errors when calculating the dosage of a drug; for example, if the instruction stipulates a particular dosage per kg of patient body weight, the nurse may need to determine what the total dosage should be for that specific patient. Finally, prescribing errors can also occur if a drug was prescribed without adequate consideration of allergies or potential drug interactions. Although these would be considered to originate from the prescriber rather than the nurse administering the drug, the nurse still has a responsibility to consider the appropriateness and accuracy of the prescribing decision in the context of their own knowledge and experience. This might mean systematically asking every patient about their medication history or any known allergies before each drug administration or questioning a prescribing decision that appears inappropriate.

Institutional Causes

Institutional causes of medical and drug administration errors can include failures in management, such as inadequate provision of staff or resources for a department, or an unclear or ineffective management structure.

An important safety consideration is that of the culture fostered within the institution with regards to patient safety. In 2013, the Francis Report published the results of an investigation into systematic failures in patient care and safety at the Mid Staffordshire NHS Foundation Trust which ultimately resulted in multiple preventable patient deaths. Although the investigation identified that the unsafe practice of a small number of midwives contributed to these deaths, the investigation also illustrated the impact that an unsafe working culture can have on patient safety.

As a result, it has been identified that increasing care transparency and reducing the fear associated with the reporting of drug administration errors and other care failures is vital in reducing medical errors. Therefore, the NMC advocates that institutions work towards establishing a working culture where errors, near misses and safety concerns can be reported and discussed in an open and supportive manner. The aim of this is to encourage more nurses to come forward by reducing the fear of disciplinary action, and therefore to identify potential safety risks at an early stage.

Nurses should also consider the potential for organisational and individual factors to overlap. This can be illustrated by the Swiss Cheese Model, published in 2000 by James Reason. The model describes how patient safety errors can occur when multiple complementary organisational errors occur simultaneously. The model considers safeguarding interventions to be generally solid but with occasional holes. If lined up together, the solid areas of safeguarding interventions should overlap the holes in other layers, so that the hole is not present throughout the layers. However, if multiple holes, or failures in safeguarding processes, occurred simultaneously or at complementary times, this could result in the hole being apparent through all the layers, indicating the possibility of the failures to break through all the current safeguarding barriers and result in a patient safety event.

Responsibilities of Nurses

The NMC Code stipulates that registered nurses are accountable for their decisions and practice, as well as being accountable for the practice of any competent individuals they have delegated a task to (NMC, 2015b). Additionally, nurses have a responsibility to report unsafe practice or issues with care quality (Hood, 2013). This responsibility is recognised by the CQC (2015), who consider that nurses are ideally placed within the multidisciplinary team to identify the unsafe practice of others, or institutional or policy issues that may have an adverse effect on patient safety. The reporting of these issues is known as "whistle blowing", and following high profile safety issues such as those outlined in the Francis Report, it has been identified that nurses should receive professional and legal protection against any negative ramifications of the reporting of patient safety concerns.

Methods of Preventing Errors

It has been suggested that the risk of human error can be reduced by considering the causative factors as part of a person-centred approach or a systems approach. Person-centred human errors can be reduced by targeting the known causative factors, such as poor motivation, inattention, negligence or forgetfulness. The risk of these could be reduced by, for example, retraining staff on a regular basis. However, a systems approach would be more effective in combatting organisational issues, such as changing the layout of drug charts if an error investigation identifies that some staff experience confusion when completing these. Systems-based approaches therefore focus more on identifying why organisational safeguarding procedures failed, rather than focusing on the individual who committed the error.

Another approach to reducing future drug administration errors is to review the current policy in relation to the direct influences behind the original error. For example, if an investigation identified that a drug administration error had occurred as a direct result of the nurse being distracted by a patient or colleague, the ward manager could consider introducing an approach such as protected medication time. Interruptions have previously been identified as a common cause of incorrect medication administrations (Ford, 2012). Under this protocol, the nurse undertaking the drugs round is clearly indicated and staff, patients and visitors can be made aware of the importance of not distracting the nurse performing the drugs round. This approach has been successfully implemented by several NHS trusts. These trusts reported a moderate reduction in the incidence of interruptions, although the overall effect on error incidences is uncertain (Beckford, 2011).

There are also novel ways in which errors can be prevented that are specific to the underlying cause. For example, the risk of errors occurring as a result of the nurse selecting the wrong drug could be reduced by using automated dispensing cabinets. These often use a barcode-based system and can restrict access to only the drawer or compartment containing the drug that should be dispensed (Cottney, 2014).

Error Reporting and Investigative Process

In the event that a nurse identifies a drug administration error, the first consideration should always be patient safety. The nurse should immediately take any action necessary to ensure that the patient is not harmed by the error, and that any harm is rectified as quickly as possible. The error should also be documented immediately in the patient's notes and any necessary paperwork indicated by local policy should be completed. The procedure for error reporting may vary between institutions due to local policy, which is usually created in accordance with NMC guidance, and a nurse should always follow this in the first instance. The NMC guidance stipulates that the nurse should immediately notify the prescribing practitioner, their line manager and their employer.

Nurses have a professional duty of candour to be honest with their patients, colleagues and management (NMC, 2015a). They should therefore be open with patients (or their next of kin if appropriate) about any medical or drug administration errors. Patients should be informed about the error, and offered any support needed to deal with any effects of the error. Patients should also receive an apology, and be assured that the correct procedure will be followed and the situation learned from to improve future patient care.

The NMC requires that drug administration errors be investigated in a full and transparent manner, in order that all contributing factors are identified so that they may be addressed. The NMC also recommends sensitive management of error investigations, as it recognises that error reporting is more likely to occur when nurses do not fear that the investigative process will automatically result in blame or discipline. Additionally, the NMC recognises the difference in management required for errors that have resulted from organisational pressures, and those that have resulted from reckless or careless behaviour. Therefore, the NMC encourages local management to also consider this difference when undertaking local disciplinary action.

In England and Wales, medical and drug administration errors should also be reported to the National Patient Safety Agency (NPSA) via the National Reporting and Learning System (NRLS) so that any lessons that can be learnt from the error can be implemented nationwide. Drug administration errors should also be reported to the CQC, who may wish to conduct an independent investigation, or to make their own recommendations to reduce the risk of the error occurring again.

Conclusion

Drug administration errors are frequent, despite research identifying common causes at both an individual and organisational level. By being aware of the causes of errors and the strategies that can be incorporated into everyday practice to prevent them, nurses can improve the safety of the care they offer their patients. Nurses and other healthcare professionals should be aware of the advantages of correct error reporting, and how this can be used to identify underlying issues and thus prevent future errors.

Reference list

Beckford, M. (2011). Nurses Wear 'Do Not Disturb' Signs During Drug Rounds. The Guardian. [Online]. Available at: http://www.telegraph.co.uk/news/health/news/8728093/Nurses-wear-do-not-disturb-signs-during-drug-rounds.html [Accessed: 23 November 2016].

Colen, H. B., Neef, C. and Schuring, R. W. (2003). Identification and verification of critical performance dimensions. Phase 1 of the systematic process redesign of drug distribution. Pharmacy World & Science, 25 (3), pp.118-125.

Cottney, A. (2014). Improving the safety and efficiency of nurse medication rounds through the introduction of an automated dispensing cabinet. BMJ Quality Improvement Reports, 3 (1), p.u204237.w1843. [Online]. Available at: http://qir.bmj.com/content/3/1/u204237.w1843 [Accessed: 23 November 2016].

CQC. (2015). Statutory Notifications. Care Quality Commission. [Online]. Available at: https://www.cqc.org.uk/sites/default/files/20150331_100501_v6_00_guidance_on_statutory_notifications_ASC_%20IH_PDC_PA_Reg_Persons.pdf [Accessed: 23 November 2016].

Ford, S. (2012). Drug Rounds Must Be Protected in Care Homes to Cut High Error Rates. [Online]. Available at: http://www.nursingtimes.net/nursing-practice/specialisms/older-people/drug-rounds-must-be-protected-in-care-homes-to-cut-high-error-rates/5040511.article [Accessed: 23 November 2016].

Ghaleb, M. A., Barber, N., Franklin, B. D. and Wong, I. C. K. (2010). The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Archives of Disease in Childhood, 95 (2), pp.113-118.

Hood, L. (2013). Leddy & Pepper's Conceptual Bases of Professional Nursing. 8th ed. Missouri: Lippincott Williams & Wilkins.

NMC. (2015a). Openness and Honesty When Things Go Wrong: The Professional Duty of Candour. Nursing and Midwifery Council. [Online]. Available at: https://www.nmc.org.uk/standards/guidance/the-professional-duty-of-candour/ [Accessed: 23 November 2016].

NMC. (2015b). The Code for Nurses and Midwives. Nursing and Midwifery Council. [Online]. Available at: http://www.nmc.org.uk/standards/code/ [Accessed: 23 November 2016].

Reason, J. (2000). Human error: Models and management. BMJ, 320 (7237), pp.768-770.

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M. and Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170 (8), pp.683-690.


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