Introduction
Medication errors are a common issue even in well-developed and technologically advanced national healthcare systems. For instance, Elliot et al. (2018) reviewed 36 studies on medication errors in the UK and concluded that error rates were comparable to those in other European Union countries and the USA. In the UK case, it was estimated that 237 million medication errors occur annually in England alone (Elliott et al., 2018). Only the avoidable adverse drug reactions resulting from medication errors cost the National Health System £98.5 million per year, caused 712 deaths, and contributed to 1,708 deaths (Elliott et al., 2018). Given this information, the problem of medication errors should be considered systemic.
The data from the United States corresponds with the systemic nature of medication errors. According to the Institute of Medicine (IOM), medication errors injure at least 1,5 million Americans annually (as cited in Campbell et al., 2018). Campbell et al. (2018) studied the community pharmacy dispensing errors in the 1993-2015 period and found that 1,5% of all prescriptions had an error. For reference, in 2005 alone, 3,6 billion prescriptions were dispensed in community settings (Campbell et al., 2018). Consequently, medication errors in the United States put millions of lives in danger every year.
Finally, research from Saudi Arabia gives an insight into the problem of non-reporting. Alsulami et al. (2019) conducted a cross-sectional survey of 365 healthcare professionals at King Abdulaziz Medical City (KAMC) hospital and found that 23,5% of respondents feared being blamed for their medication errors. The error reporting rate among the participants at KAMC was 55,2% (Alsulami et al., 2019). Therefore, one can conclude that the systemic nature of medication errors is worsened by problems in identifying and reporting such errors.
Definitions of Medication Errors
The issue of medication error definition is quite complex due to multiple interpretations of the concept. An article by Dirik et al. (2019) offers two definitions provided by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) and IOM, respectively. According to the NCCMERP (2016), “medication error is any preventable event that may cause or lead to inappropriate use of medication or patient harm while the medication is in the control of healthcare professional, patient, or consumer” (as cited in Dirik, 2019, p. 932). The IOM’s (2001) definition is wider because it includes not only the errors of the commission but errors of omission as well (as cited in Dirik et al., 2019, p. 932). From this standpoint, a medication error may occur when healthcare professionals do not take action.
The more specific definitions are usually derived or directly adapted from the NCCMERP’s or IOM’s definitions of medication error. For example, in their review of electronic prescribing strategies’ effect, Roumeliotis et al. (2019) included such definitions of medication errors as incomplete prescriptions, dose frequency errors, transcription errors, and errors in dispensing and administration. Palmero et al. (2019) used a definition adopted by the Clinic of Neonatology of Lausanne University Hospital, which classifies all medication errors by severity. Minor errors do not require any therapy or special monitoring, whereas serious ones result in life-threatening conditions or death (Palmero et al., 2019). Overall, the definition of medication errors can be quite broad, and the only common aspect among them is an association with potential harm to a patient’s health.
High-Alert Medication Errors
High-Alert Medications (HAMs) can be defined as medications that have an increased risk of causing harm to a patient when used in error. A list of such medications includes but is not limited to antithrombotic drugs, antidiabetics, opioids, sedatives, and anesthetics (Sessions et al., 2019). Nursing personnel must be especially cautious in using HAMs; however, several barriers to HAM administration safety exist. Sessions et al. (2019) interviewed 18 acute care nurses and found that errors in HAM use were associated with distractions, workload, and patient acuity. Nurses developed potentially dangerous workarounds, such as bypassing barcode scanning and independent double-check procedures (Sessions et al., 2019). Therefore, healthcare organizations should invest in developing an organizational culture that emphasizes safety and collaboration.
Double-check is a common practice for error prevention in HAM use. However, the effectiveness of double-checking varies significantly depending on the error type. Douglass et al. (2018) studied 43 pairs of nurses divided into the single-check and double-check groups. In the single-check group, 54% of nurses detected wrong vial errors compared to 100% in the double-check group (Douglass et al., 2018). The weight-based dosage errors were detected only by 9% of nurses in a single-check group and 33% of their colleagues in double-check group (Douglass et al., 2018). Given these numbers, double-checking should be implemented but not considered a universal defense against medication errors.
An identification of HAMs regularly used in a particular healthcare organization can serve as an additional safeguard. For instance, Schepel et al. (2021) analyzed 401 adverse drug reactions and 11,668 medication error reports from Helsinki University Hospital and compared them to the Institute for Safe Medication Practices (ISMP) list of HAMs. Consequently, Schepel et al. (2021) were able to create an organization-specific list of HAMs. Such an approach can be used to instruct nurses on which medications must be administered with extra caution.
Medication Administration Errors in Nursing
Medication administration errors (MAEs) occur due to various barriers that prevent error identification and disrupt reporting procedures. Hammoudi et al. (2018) surveyed 367 nurses at a tertiary hospital in Riyadh, Saudi Arabia, and revealed that similarities in medication packaging, appearance, and names were the most influential factor in MAEs. Poor communication was the second-strongest cause of errors (Hammoudi et al., 2018). Regarding the non-reporting of MAE cases, nurses listed potential administrative response, fear, and disagreements about the definition of error as the most frequent causes (Hammoudi et al., 2018). The possible solutions to these problems include training in professional communication and implementation of healthcare information technologies, such as clinical decision support systems.
Creating a sense of safety is especially important since nurses are often reluctant to report errors out of fear of being punished. For example, Kiymaz and Koç (2018) surveyed 284 nurses from 19 Turkish hospitals and found that 40,1% of the respondents had previously witnessed medical and medication administration errors, and 19,4% made such errors themselves. However, none of the survey participants reported error cases (Kiymaz & Koç, 2018). In this regard, healthcare organizations should examine the nurses’ perspectives and determine the factors that cause errors. For instance, Keers et al. (2018) interviewed 20 nurses working in mental health hospitals and found that MAEs are caused mainly by concentration lapses and skill-based slips. Consequently, factors like inadequate staffing levels, distractions, and unbalanced skills of the nursing team should be addressed to create an environment that reduces the MAE number.
Digital Learning Tools for Training Nurses in Medication Administration
Several sources confirm the value of digital learning tools such as mobile apps and e-learning modules for training nurses in medication administration and medication error avoidance. For instance, Siebert et al. (2019) developed a mobile app as a step-by-step guide for the preparation for drug delivery requiring continuous infusion. The app was tested by randomly assigned 128 nurses at six pediatric centers in Switzerland. Out of 128 preparations made with a standard infusion-rates table, 96 were associated with medication errors; at the same time, 128 preparations made via mobile app resulted in nine errors (Siebert et al., 2019). Therefore, a mobile app proved its value for MAE prevention in pediatric clinical practice.
Digital learning tools proved their usefulness in teaching behavioral strategies that reduce the harmful effects of interruptions during medication administration. Johnson et al. (2018) tested a special e-learning module on a sample of nine registered nurses in Sydney, Australia. The module contained factual information on medication errors and interruptions, videos describing positive and negative examples of reactions to interruptions during medication administration, and interviews with experienced healthcare professionals (Johnson et al., 2018). At the end of the experiment, the nurses reported increased awareness about the harm of interruptions and changed their behavior to be more focused on medication administration (Johnson et al., 2018). These results can be considered positive since distractions were reported as one of the most influential factors in medication errors.
Conclusion
Finally, a variety of digital learning tools was confirmed to be beneficial for increasing the medication safety competence of undergraduate nursing students. Lee and Quinn (2019) reviewed twelve original research articles and confirmed the beneficial impact of simulation experiences, technology aids, and online learning modules. For example, Holland et al. (2013) made a video displaying the best practices of oral medication administration and demonstrated it to 154 out of 322 undergraduate nursing students across the sample. In the end, fewer students from the group that had access to the video failed the exam or had low scores (Lee & Quinn, 2019). Overall, nursing schools should consider using digital tools in medication safety training if the necessary technical conditions and resources are available.
References
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