Toolkit for Reduction of Medical Administration Errors for Nurses

Toolkit for Reduction of Medical Administration Errors for Nurses: An Annotated Resource
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Toolkit for Reduction of Medical Administration Errors for Nurses: An Annotated Resource
In December 2017, a nurse was charged for homicide after a 75 years old patient was injected with paralytic anesthetic vecuronium instead of the prescribed Versed sedative (Loller, 2019). Earlier the same year, an $800,000 federal government settlement was awarded to the family of an Air Force veteran following a medical error (Ross, 2019). The veteran was injected with pegfilgrastim instead of filgrastim at Dorn VA hospital in North Carolina. Three years earlier, 2650 miles to the West of North Carolina, in Sacramento (CDMH, 2014), the California Department of Public Health penalized a long-term acute-care facility $75,000 for a medical error administered by a patient an excessive amount of Levophed. These three cases are supposed to highlight the prevalence and seriousness of nursing medical errors. What is standard across the cases is that all the patients succumbed. According to the FDA (2019), over 100,000 suspected cases of medication errors are reported annually.
Annotated Bibliography
Therefore, the current paper provides an information tool kit focusing on promoting safety with medication administration. The bibliographic narration focuses on four key themes: most common errors, causes of errors, their impact, and potential solutions.
Most Common Errors
MacDowell, P., Cabri, A., & Davis, M. (2021, March 12). Medication Administration Errors. Patient Safety Network.  HYPERLINK "https://psnet.ahrq.gov/primer/medication-administration-errors" https://psnet.ahrq.gov/primer/medication-administration-errors
The authors assert that since the 1990s, medication errors have remained a key target for improving patient safety within health facilities. The authors establish five categories of errors: right patient, medication, time, dose, and route. Additional rights added years later focus on correct documentation, reason, response, and form. With the advancement in technology, system design is also an important aspect. Since nurses interact with patients in medical facilities and homes, errors are bound to occur in both places. The authors conclude that the most common errors include missing doses, wrong medication, and wrong dose.
Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1), 1-9. The authors undertook a cross-sectional study focusing on tertiary hospitals in Addis Ababa, Ethiopia. The purpose of the study was to determine the most common medication errors and the contributing factors among nurses in the region. A self-administered survey questionnaire was completed by 298 nurses selected randomly. The study found that, for various reasons, 68.1% of respondents had committed a medication administration error. The standard errors found among the nurses include wrong dosage, missing dosages, and wrong medication. Some of the reasons for the errors include lack of adequate training, inadequate work experience, interruptions during medication administration, and inaccessibility of appropriate guidelines.

1. Härkänen, M., Vehviläinen-Julkunen, K., Murrells, T., Rafferty, A. M., & Franklin, B. D. (2019). Medication administration errors and mortality: incidents reported in England and Wales between 2007 ̶ 2016. Research in Social and Administrative Pharmacy, 15(7), 858-863.

In this research, the authors analyzed the 517,384 reported cases of medical errors in England and Wales between 2007 and 2016. Out of these records, 229 were found to have resulted in death. They established that a majority (66.4%) of errors occur in wards while a further 41.5% impacted patients aged 75 years and above. The most common error established was the omission of medicine or critical ingredients. Cardiovascular drug groups were most involved in the errors, followed by the nervous system drugs category. For children under the age of 12 years, errors result from drugs that treat infections.

Causes of Errors

1. Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 220.

            The purpose of the study was to establish the causes of medication errors and investigate effective prevention strategies. 327 qualified nursing staff and an additional 62 intern nursing students in Iran were involved in the study. The article is essential because it provides the nurses' perspective on the topic. The researchers established that tiredness and fatigue resulting from excessive workload was the primary causative factor of medical errors among nurses. Among nursing students, the primary cause of errors was a poor calculation of drug dosages.

1. Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: a qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38-53.

            Schroers and colleagues assert that since nurses are often responsible for medication administration, their perceptions on causes of errors should be a key point of focus in improving patient safety. The authors conducted a literature review of publications from 2000 to 2019 to determine what existing literature says about medication errors from nurses' point of view. In their findings, they categorized causes of errors into knowledge-based and personal factors. In the former, lack of medication knowledge was the key theme. In the latter, heavy workload and interruptions were the leading causes of errors in medication administration.

1. Nkurunziza, A., Chironda, G., Mukeshimana, M., Uwamahoro, M. C., Umwangange, M. L., & Ngendahayo, F. (2019). Factors contributing to medication administration errors and barriers to self-reporting among nurses: a review of literature. Rwanda Journal of Medicine and Health Sciences, 2(3), 294-303.

            In this article, the authors argue that medication administration errors (MAE) are common, threaten patient health outcomes and satisfaction, and are the leading concern for patient safety within medical facilities. The authors conducted a review of the literature to establish the leading causes of MAE. The findings show that overworked nurses are more likely to commit these areas. A key finding in the research suggests that there exist many barriers to self-reporting (including fear of disciplinary action and distribution of executive power) and that variations in age, experience and education determined the probability of self-reporting.

Impact of Err...