Summary of Studies Involving Medication Errors (ME)
Purpose
Sample
Design
Measurement
Results/Conclusions
Ranking
Cohen, H., Robinson, E. S., & Mandrack, M. (2003). Getting to the root of medication errors, Nursing 2003, 33(9), 36-45.
Describe nurses’ attitudes and experiences regarding medication administration and error reporting
N = 775
Convenience sample of Nursing 2002 readers
RNs and students across all specialties and settings
Descriptive survey
21 item questionnaire included in a nursing journal
Top five reported causes of errors:
Distractions and interruptions during administration
Inadequate staffing and high nurse/patient ratios
Illegible written orders
Incorrect dosage calculations
Similar drug names and packaging
Rothschild, J. M., Keohane, C. A., Cook, E. F., Orav, E. J., Burdick, E., Thompson, S., Hayes, J., & Bates, D. W. (2005). A controlled trial of smart infusion pumps to improve medication safety in critically ill patients, Critical Care Medicine, 33, 533-540.
Study the effect of smart infusion pumps on ME
Study conducted in an academic medical center
N = 744 admissions
(735 cardiac surgery patients in a cardiac surgical intensive care or step down unit)
Prospective randomized time series experiment
IV: Infusion pumps programmed with decision support programmed (alerts, reminders, unit specific drug rate limits)
DV: number of serious ME
Data contained in the log reports from infusion pump software
Events in the log rated by physicians for type, preventability, and severity
180 serious ME identified
Rate for the control group was 2.03 and the rate for the intervention group was 2.41 per 100 patient pump days
There was no statistical benefit from pump software
Data log demonstrated that elimination of ME is possible but RNs must be educated to use the software features appropriately
Citation (APA)
Purpose
Sample
Design
Measurement
Results/Conclusions
Ranking
Coiera E.W. & Tombs V. (1998). Communication behaviours
in a hospital setting: An observational study.
BMJ, 316, 673–676.
To define the effort of the surroundings of the
clinic nurses with specific
attention on the presentation of labor
organizations providing info,
resources, and apparatus for
Patientcare.
11 RN
Straight unstructured
scrutiny
Mixed
Observed all the departments where all the nurses were working.
Interruptions are characterized as being
initiated mainly by nurses themselves and other members
of the nursing team, conveyed through face-to-face interactions,
occurring for patient management purposes, and are
of short duration.
There is some evidence that medication
administration is the most interrupted nursing activity, especially
in the room where medications are prepared
Citation (APA)
Purpose
Sample
Design
Measurement
Results/Conclusions
Ranking
Barker K.N., Flynn E.A., Pepper G.A., Bates D.W.&Mikeal
R.L. (2002). Medication errors observed in 36 health
care facilities. Archives of Internal Medicine, 162, 1897–
1903.
To identify the features of the
communication load on the nurse in
charge of the ED
11 RN (nurse in charge)
Direct structured
observation and
audio-recording
Direct observation
Conducted a direct observation to all the nurses on duty on that specific day.
Using direct observation
to collect data on both work interruptions and the rate
of medication administration errors, a significant positive
association between interruptions and rate of medication
errors is present when the wrong time category is excluded
(p = 0.01). The relationship is also present and significant
(p = 0.04) between work interruptions and the rate of
medication errors when wrong time medication errors are
included but the relationship is inverse