A medication error is a preventable incident that may cause or lead to inapt medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. A medication error may relate to professional practice, health care products, procedures, and systems. This includes prescribing; order communication; product labeling, packaging, and nomenclature; compounding; and dispensing. It also includes distribution; administration; education; monitoring; and use (IOM 2007).
Anselmi and others (2007) identified that many nurse technicians, attendants and auxiliary nurses work without technical qualification. This represents a source of potential risk that produces errors threatening the patients’ health outcome. Responding to this problem, they designed a cross sectional study involving three Brazilian hospitals in the state of Bahia aiming to verify the different types of errors in intravenous drug administration by the nursing working force. Anselmi et al (2007 p, 1842) defined intravenous administration error as a dose either prepared or administered by a nurse that differs from that prescribed or written on a patient’s record. Therefore, in collecting data they observed nursing errors in the areas of medication preparation and administration. Further, they observed nursing errors before (pilot study) and after theoretical and practical training in a teaching hospital. Results suggested that wrong dose and omission dose were the commonest errors while, wrong patient error was not reported in any of the three hospitals surveyed. They inferred the rate of errors was low compared with other studies, but showed variations in frequency among the three hospitals; however they did not provide an explanation of the causes and working conditions for such variability.
Critiquing the article of Anselmi et al (2007)ю
The authors recognized the process in medication administration is an important hospitals’ issue and selected errors in intravenous drugs administration to investigate being of complex technology and serious outcomes. The authors, however, clarified neither the conceptual framework of medication errors nor the complexity of the process of drug administration and how they relate to the types of medical errors.
The report titled to err is human was issued by the US Institute of Medicine in 1999 has triggered increased awareness of medical errors as a serious threat to patient safety. The central concepts of the report were that improving healthcare quality can not be addressed without addressing the key component of patient safety. Additionally those errors are not in core a result of professionals’ incompetence bad intents or lack of hard work (Leap and Berwick, 2005). Motivated by the report’s impact, Stelfox and others (2006, p.174) conducted a literature review on patient safety and medical errors. They examined 5514 English language published articles between 1994 and 2004 and inferred the report resulted in a significant increase in research on patient safety and medical errors. However, there is a need to examine whether research resulted in safer patient care.
The basic concepts provided by the report are; first, understanding of medical errors depends on structuring the possible causes of errors and coupling them with reliable ways of reducing them. Second, designing guidelines and implementation of technology use should build on human strengths meaning to consider seriously the human factor. Third is to avoid dependence on personnel’s’ vigilance by relying on standardizing and simplifying key processes and equipments, and to pay attention to work safety. Fourth, adding team and multidisciplinary training concepts to training programs. Finally, the report emphasized involving patients, families and other stakeholders in planning patients’ care (Hendriksen et al, 2005 pp. 375-385).
The processes included in the overall medication process are prone to error and the nursing role in each sub-process varies from responsible to contributing. First, is prescribing and ordering, which is primarily the responsibility of the physician, however, the nurse’s role, especially the advanced practice nurse, to inquire from the prescriber (Cook et al 2004). Second is writing out, dispensing and delivery where the nurse’s role differs in different hospitals’ settings where the nurse administration either alone or in association with pharmacists contributes to this process. Third is medication administration where the nurse is or should be the only responsible staff member for this process (Walsh et al, 2005). In addition, nurses are not the only staff members to administer medications, physicians, certified technicians and assistant occasionally do. Thus, part of the challenge in understanding the impact of nursing errors in medications administration is to distinguish the errors of each group and not to include it all as medication administration errors (Hicks et al, 2004). Therefore, the workplace environment should ensure the nurses’ rights as regards medication administration, Cook (2006) summarized the rights as the right to have clearly written medication orders with precise specification about the drug, dose, route and frequency of administration. Nurses have the right to have the correct drug dose and route dispensed by pharmacists and the right to have access to drug information.
Having clarified the conceptual framework and the medication processes prone to error, the types of errors can be outlined. Medication errors can be classified into wrong drug, dose, patient, technique; or wrong time, frequency or test. Other technical nursing medication errors include administering drugs with known allergy, drug-drug interaction, or inefficient monitoring or preparation error (Wolf and Serembus, 2006). The authors classified medication errors into medication preparation and medication administration errors. Trials to sort medication errors according to the adverse effect or to the stage of drug administration process are in progress yet not complete (Kopp et al, 2006). Kopp and others (2006, p. 415) agreed the commonest drug administration errors are that wrong dose, dose omission, wrong drug and wrong time. Williams (2007, p. 345) classified medication errors into errors in action planning (mistakes) and errors in performing planned actions correctly (skill-based errors). Mistakes include either knowledge-based or rule-based errors, while skill-based errors are either action-based (technical) or memory-based. If the aim is prevention, this classification may be more useful in targeting education and training to the defect in drug administration guided by research.
The authors’ literature reviews focused on the distribution of nursing workforce pointing to qualified nurses are minority and are involved in administrative work than technical one. Then they reviewed the literature on errors with intravenous administration medications; however the review centred on observational studies showing the incidence of these errors in Brazil and Western countries. The rate of IV medication errors differ in various nursing hospital settings, as in ambulatory care, intensive care, paediatric, and pre anaesthesia. Besides, the authors did not specifically point to preventable medication error, where training is supposed to produce an effect. Parshuram et al (2008, p. 42) performed a systematic review of intravenous preparation medication errors on 118 health care professionals involved in preparing IV medication as a part of their clinical activities. The authors identified there are five steps included in IV medication preparation, which are drug volume calculation, rounding that calculating the concentration to the nearest integer or power of ten. Preparation of IV medication also includes volume measurement, mixing and dose-volume calculation. The authors inferred the commonest preparation error is concentration calculation (34.7%), followed by drug volume calculation (5%), rounding was next (2.5%) followed by volume measurement (1.9%). Volume calculation was the least frequent (1.6%), they inferred that frequency of error relates to nursing years of experience, workload and fatigues and volume of dose prepared. Recognising the high patient vulnerability and the high patient safety culture in intensive care units, Valentine et al (2009, p. b814) conducted an observational prospective cross sectional study on errors of parenteral medication administration in 113 IC units of 27 countries. Results showed an incidence of 74.5 error event per 100 patient days, nearly 75% of these errors were omission errors. The authors inferred these errors are common representing a serious patient safety issue in ICUs and the complexity of patient care in intensive care units may be a contributing factor. Shane (2009, p.S44) identified that 54% of medication adverse effects and 61% of serious of life threatening hospitals incidents are linked to errors in IV medication administration. However, only 6% of countries participated in the Global Hospital pharmacy Survey pointed that IV medications are prepared by pharmacists. In UK a study reported an error rate of 49% in administration or preparation and the rate increased to 73% with one shot fast injections (bolus). Shane (2009) reviewed the literature on global rate of errors and inferred that wrong rate of administration and calculation errors are the commonest. One way to minimise these common errors is the use of infusion devices, however as Shane (2009) reported that lack of understanding of how to operate the device links to higher errors rate in some countries.
The State of Bahia, Brazil characteristically has a high rate of urbanisation (67.4%), which is immigration of people from rural to urban areas thus affecting population density and administration services (data from the Brazilian Institute of Geography and Statistics website; http://www.ibge.gov.br/english/default.php). The last National research for Sample of Domiciles census (data obtained from http://brazilian.worldvitalrecords.com) shows that population configuration of Bahia is 62.9% Brown, 15.7% Black, 20.9% White, and 0.6% Asian. This demographic trend and population diversity mandate a look into both human factor and patient safety culture, which the authors did not fully explain their impact on nursing errors having chosen Bahia as their area of research.
The human factor in medications errors
There are two major strategies to reduce the possibilities of medication errors, first is the individual-centered strategy, which focuses on those who make the errors. Second is the system-centered strategy, which claims that procedures can be redesigned to reduce and detect medication errors. Both recognise the importance of the human factors in producing successful outcome of either strategy (Etch ells et al, 2008). Human factors include the characteristics of providers like mathematical and cognitive skills, the nature of clinical work like length of nursing shifts, need for vigilance and attentiveness, time pressure and staffing level and equipment and technology interface. Length of nurse experience and level of training and education influences the outcome of care. The human factors also include institutional environment that affect the human factor like the design of physical environment like patient rooms, facilities and beds, policies, guidelines for procedures and administration awareness of patient safety concerns. There a great number of studies on the human factor and all emphasize its importance in reducing the medication errors rate (Aspden et al, 2007).
Despite the advances in the science of patient safety; yet, a significant reduction in the frequency of medical errors is still to achieve. Research from the field of human factors has shown that attention, perception, and cognition are all unsound, and the research. The next frontier is to address patient safety culture on all levels, care providers, health care administrative and the public. The claim that to achieve high levels of patient safety needs technological tools may prove untrue unless safety culture and effective care are adequately addressed (Hughes, 2008). Johnstone and Kanitsaki (2006, p. 383) reported the significant influence of culture on health care is internationally appreciated. Further, they suggested that failure to identify the relationship between culture and patient safety is a major barrier in minimising medication administration errors and it is important that the public shares health care providers the concept of patient safety culture. The relationship between health care organizational culture and work performance is well-built since culture endorses a safe working environment where errors are identified and reported; thus, ensuring effective health care delivery. The core of health safety culture is why the error took place not who committed the error, in the frame health safety culture differs from the culture of blame (Hecht et al, 2005).
Study design and methods
Cross sectional studies measure patterns of exposures and outcomes. Thus, if the exposure of interest is X, the outcome of interest is Y and all other variables are measured in the selected population at one point of time, then the association between X and Y can be measured. They have the advantages of being quick, cheap, examine associations and provide a description of the case studied; however, they are prone to selection bias and show association not cause effect relationship (Sheskin, 2004). These studies are particularly prone to the time-length bias where long duration exposures will be over represented resulting in ambiguity of temporal associations (Szklo and Nieto, 2004). Observation method in cross sectional studies is probably the most effective method in evaluating medication administration error. Further, performing observation methodology does not appear to influence thought sequence or distract nurses during their work (Ulanimo et al, 2007).
Points of strength
The authors provided a comprehensive review on the incidence of intravenous administration medication error and highlighted the studies made in Brazil enriching the literature about this country. The authors used cross section study with observation methodology to enhance fidelity and reliability of data collection. For further objectivity in data collection, data collection was through a checklist, and monitoring of the collection process was done on daily basis by the study supervisor and the authors.
Points of weakness
The authors did not clarify the theoretical framework of the study; in addition, they did not clarify the role of human factor. Although the study is the second to a previous one in the same state, yet the authors did not compare the results of both studies. Further, they did not specifically point to the of teaching hospital training on the error rate. The authors did not address the supervising nurse role in drug preparation or administration, if any, or their role in promoting patient safety culture. As nurse are in an exceptional position to promote patient safety culture because of their innate propinquity to patients. This provides the needed insight to identify safety problems in health care system (Page, 2004). The training program provided in the study did not address promotion of patient safety culture. The authors did not explain why their results differ significantly in one of the three studied hospitals; also they did not associate errors with human factors. Although this is the second study conducted in the same state, the authors did not provide recommendation for improvement or how to effectively promote the nurses’ role in intravenous medication administration. Finally, cross sectional studies do not measure incidence as the authors mentioned in their conclusion, which is an inherent problem in this methodology. The can only estimate the association among variables.
Medication administration errors result from a combination of various factors, In Bahia State, Brazil; it appears that nurses are a minority of the nursing workforce and medication administration is mainly the responsibility of nursing technicians, assistants or nursing auxiliary. In such a situation, enhancing the nurses role in supervising drug administration especially IV drugs, supporting the nurses’ role in promoting patient safety culture may represent the way to reduce incidence of this type of errors.
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