Nurse perceptions of medication errors

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J Nurs Care QualVol. 19, No. 3, pp. 209217c 2004 Lippincott Williams & Wilkins, Inc.

Nurse Perceptions ofMedication ErrorsWhat We Need to Knowfor Patient Safety

Ann M. Mayo, DNSc, RN; Denise Duncan, RN

This study describes nurse perceptions about medication errors. Findings reveal that there are dif-ferences in the perceptions of nurses about the causes and reporting of medication errors. Causesinclude illegible physician handwriting and distracted, tired, and exhausted nurses. Only 45.6% ofthe 983 nurses believed that all drug errors are reported, and reasons for not reporting includefear of manager and peer reactions. The study findings can be used in programs designed to pro-mote medication error recognition and reduce or eliminate barriers to reporting. Key words:medication errors, nursing, patient safety, reporting

MEDICATION errors strike at the heartof being a nursethe responsibility todo good and avoid harm. Medication errorshave serious direct and indirect results, andare usually the consequence of breakdownsin a system of care. Direct results includepatient harm as well as increased healthcarecosts. Indirect results include harm to nursesin terms of professional and personal status,confidence, and practice.

Everyone concerned about patient safetyequates medication errors with serious risksto patients. Medication errors also impact or-ganizations and nurses. Ten to 18% of all re-ported hospital injuries have been attributedto medication errors.1,2 Five percent of allmedication errors reported to the US Food

From the Kaiser Permanente, California Division,San Diego, Calif (Dr Mayo); and UNAC/UHCP,Pomona, Calif (Ms Duncan).

We thank the United Nurses Association of California/Union of Health Care Professionals (UNAC/UHCP) andthe Southern California Kaiser Permanente Nursing Re-search Program for supporting this study.

Corresponding author: Ann M. Mayo, DNSc, RN, KaiserPermanente, California Division, 3033 Bunxer Hill,San Diego, CA 92109 (e-mail: [email protected]).

Accepted for publication: November 17, 2003

and Drug Administration (FDA) in 2001 werefatal.3 United States data from 1993 indicatethat 7391 patients died from medication er-rors, and patient stays associated with medi-cation errors increased by 4.6 days, with a re-sulting cost increase of $4685 per patient.1 Inthe state of California alone, over 700 patientsdie each year because of medication errors.4

MEDICATION ERRORS

Medication errors are typically defined asdeviations from a physicians order. Hospitalmedication error rates can be as high as 1.9per patient per day.5 Sources of errors includeillegibly written orders, dispensing errors, cal-culation errors, monitoring errors, and admin-istration errors (ie, giving the wrong medica-tion to the patient). Physicians, pharmacists,unit clerks, and nurses can be involved in theoccurrence of medication errors.5 A single pa-tient can receive up to 18 doses of medicationper day,6 and a nurse can administer as manyas 50 medications per shift.7 This places thenurse at the front line when it comes to drugadministration accountability.8,9

Medication errors negatively affect nurses.The psychological trauma caused by commit-ting a medication error can be overwhelm-ing to a nurse. First, nurses worry about the

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210 JOURNAL OF NURSING CARE QUALITY/JULYSEPTEMBER 2004

patient. Nurses may feel upset, guilty, and ter-rified about making a medication error. Inaddition, they can experience a loss of con-fidence in their clinical practice abilities. Fi-nally, they can feel anger at themselves as wellas the system.10

No studies have demonstrated strong rela-tionships between nurse characteristics (ie,age, years of practice, and education) andnumber of medication errors.11,12 This wouldseem to indicate that any nurse is potentiallyat risk for making a medication error.

REPORTING MEDICATION ERRORS

Whether the nurse is the source of an error,a contributor, or an observer, organizationsrely on nurses as front-line staff to recognizeand report medication errors. Several stud-ies have demonstrated underreporting amongnurses.10,1215 Adding to the burden of report-ing, more than 90% of the self-reports arepaper-based in California.16

Prevention of medication errors is linkedto accurate reporting of medication errors.Reporting medication errors is dependent onindividual nurses decision making.15 Under-reporting or not reporting medication errorsconceals flawed systems.1

Currently, self-reported medication errorsprovide minimal information to organizationsbecause discrepancies, in terms of reported-to-actual rates, are widespread. Medicationerrors are typically reported through insti-tutional reporting systems such as incidentreports.15 Moore, however, estimated that or-ganizations relying on incident reports to pro-vide data miss up to 95% of the medicationerrors.17 Reports are generated by the nursewho identifies the error and then are for-warded to management, quality departments,or risk management departments. Reportingsystems are dependent on the nurses (1)ability to recognize an error has occurred,(2) belief that the error warrants reporting,(3) belief that she/he has committed the er-ror, and (4) willingness to overcome the em-barrassment and fear of retaliation for hav-ing committed a medication administrationerror.13

Nurses themselves believe only 25% of allmedication errors are reported using incidentreports. Only 3.5% of the nurses in the studyof Osborne et al believed that all medicationerrors are ever reported.12 Nurse managersand physicians also believe that medicationerrors are underreported by nurses.13 Errorsof both commission and omission go unre-ported. Failure to administer a medication isthe most underreported error because nursesperceive that patients will not be harmedin this situation. Conversely, errors resultingin overmedication are the most frequentlyreported.13

Nurses deliberately decide to not reportsome medication errors.18 It is estimated that95% of medication errors are not reported be-cause staff fear punishment.1 Disciplinary ac-tions including job loss also affect reportingrates.10,12,13,15Staff nurses also fear being re-vealed and labeled as someone who has madea medication error. Nurses and nurse man-agers report that they fear for the reputationof their service or unit.13,19

Other reasons for not reporting medicationerrors include disagreement over the defini-tion of an error and the need to report it aswell as the degree of reporting effort, ie, timeto complete reports.15 Interestingly, Osborneet al found that 15.8% of the nurses in theirstudy were unsure as to what situation con-stituted a medication error, and 14% were notsure when to report the error.12

Most of these studies have limitations thatinclude an inadequate number of sites (eg,one hospital) and units (eg, one medical andsurgical unit). It is difficult to know to whatdegree the local culture influences nurse per-ceptions about medication errors in these lim-ited site studies. Nonrandom sampling andsmall sample sizes raise additional method-ological issues.

No matter what reporting mechanisms,policies, or procedures are in place, report-ing medication errors remains dependent onthe nurses ability to detect medication er-rors and individual nurses decision making toreport medication errors. The Joint Commis-sion on Accreditation of Healthcare Organiza-tions (JCAHO) states that root cause analysis,


Nurse Perceptions of Medication Errors 211

while analyzing underlying systems, must in-clude an assessment of the human and otherfactors.20 For various reasons, possibly in-cluding nurse inability to detect medicationerrors, perceptions that certain medication er-rors will not harm patients, or fear of conse-quences associated with reporting, nurses donot report all detected medication errors. Thisstudy was undertaken to understand moreabout nurse perceptions of medication errorsand reporting.

METHOD

This study examined the perceptions ofmedication errors among a large number ofrandomly selected nurses in multiple settings.More specifically, it was designed to investi-gate what nurses believe constitutes a med-ication error, what is reportable, and whatbarriers to reporting exist. A self-report sur-vey method was used to collect data forthis descriptive, correlational study. The cur-rent study replicated a study conducted byOsborne et al by using a larger sample ofnurses working in more diverse settings.12

Population and sample

United Nurses Association of California/Union of Health Care Professionals (UNAC/UHCP) union-represented registered nurses(RNs) practicing in 16 Southern Californiaacute care hospitals represented the studytarget population of 9000 acute care nurses.Work settings consisted of private, govern-ment, military, and health maintenance orga-nization hospitals.

A random sample of 5000 RNs was se-lected from the above population. Accordingto Roscoe21 a final sample size of 1000 RNswould be optimal for this type of study. In2 previous studies that used this studys in-strument, response rates ranged from 61.9%12

to 79%.10 Historic response rates for surveysmailed to UNAC RNs ranged from 25% to40%. So, taking a conservative approach, 5000UNAC RNs were mailed surveys in an attemptto obtain a final sample size of approximately1000 participants.

Instrument

The Modified Gladstone12 was chosen tocollect data for this study. This instrumentmeasured (1) nurse perceived causes of med-ication errors (10 items); (2) percentageof drug errors reported to nurse managers(1 item); (3) types of incidents that wouldbe classified as (a) medication errors, (b) re-portable to physicians, or (c) reportable us-ing an incident report (6 items); and (4)nurse views about reporting medication er-rors (6 items). For the purpose of this study,one additional item was added to types ofincidents that reflected a therapeutic druglevel medication scenario. The last portion ofthe instrument captured nurse demographicdata (11 items). Instrument content valid-ity was determined acceptable by previousinvestigators.10,12 In addition, Osborne et alestablished reliability using the test-retestmethod (0.78) in their sample.12

RESULTS

Nine hundred eighty-three RNs respondedto the survey, representing a 20% returnrate. Similar to nurses across the country, theRN mean age was 44.6 years (range = 2374 years; SD = 9.07). Nurses were primar-ily female (95%), had been practicing for anaverage of 18.7 years (range = 145 years;SD = 9.94), worked full time (62.7%), andwere in benefited positions (88.2%). Simi-lar to the state of California RNs, the eth-nic backgrounds of the study participantswere varied (49% white, 34% Pacific Islander,8% Hispanic, 4% African American, and 4%other), as was their highest level of edu-cation (11% diploma, 40% associate degree,44% bachelors degree, 3% masters degree,and 3% other). Nurses represented all work-ing shifts (42% day, 18% evening, 17% night,12% 7 AM7 PM, 8% 7 PM7 AM, and 4%other). Medical/surgical (M/S), critical care,and maternal child health (MCH) practicesettings were represented (Table 1). Over-all, the RNs responding to this survey wererepresentative of nurses working in SouthernCalifornia.



Table 1. Nurse practice settings (Top 10reported)

Setting % (n)

Adult critical care 13.5 (133)Labor and delivery 9.7 (95)NICU (neonatal intensive 9.4 (92)

care unit)DOU/telemetry 7.9 (78)Perioperative 6.1 (60)Medical 5.8 (57)Operating room 4.8 (47)Surgical 4.5 (44)Pediatrics 4.2 (41)Emergency department 3.5 (34)

DOU, definitive observation unit.

As part of the demographic survey, RNswere also asked the number of medication er-rors they could remember making over thecourse of their career. The mean number oferrors recalled was 4.9 per nurse (range =0100; SD = 5.67). However, most nurses(68.3%) recalled making 2 to 5 errors overtheir career.

Analysis of the data focused on address-ing the study aims that were to describe the

Table 2. Ranked causes of medication errors

Item Mean SD

Drug errors occur when the physicians writing on the doctors order form isdifficult to read or illegible.

3.92 2.60

Drug errors occur when nurses are distracted by other patients, coworkers, orevents on the unit.

4.15 2.98

Drug errors occur when nurses are tired and exhausted. 4.30 2.82Drug errors occur when there is confusion between 2 drugs with similar names. 4.55 2.35Drug errors occur when the nurse miscalculates the dose. 5.20 2.16Drug errors occur when the physician prescribes the wrong dose. 5.46 2.50Drug errors occur when the nurse fails to check the patients name band with the

Medication Administration Record (MAR).5.87 3.06

Drug errors occur when the nurse sets up or adjusts an infusion device incorrectly. 6.13 2.37Drug errors occur when the medication labels/packaging are of poor quality or

damaged.7.52 2.53

Drug errors occur when nurses are confused by the different types and functionsof infusion devices.

7.74 2.13

Ranking: 10 indicates least frequent cause; 1, indicates most frequent cause.

following:1. nurse perceived causes of medication

errors,2. nurse evaluation of medication scenar-

ios,3. nurse perceptions about reporting

medication errors, and4. relationships between nurse characteris-

tics (demographics) and perceptions re-garding medication errors.

Causes of medication errors

Table 2 portrays the ranked causes of med-ication errors as perceived by the participat-ing RNs. Nurses ranked the listed causes from1 to 10, with 1 indicating most frequent causeand 10 indicating least frequent cause. Meanscores were calculated for each item and arelisted in the table. The top 3 ranked (out of10) perceived causes of drug errors were thefollowing: (1) MD handwriting is difficult toread or illegible, (2) nurses are distracted, and(3) nurses are tired and exhausted.

Medication scenario evaluation

Based on 6 quite different scenarios pre-sented to the nurses, Table 3 represents how



Table 3. Classifying and reporting of medication errors

%

Item Yes (n) No (n)

A patient misses his midday dose of oral ampicillin because he was inx-ray for 3 h.

Drug error 21.3 (200) 78.7 (740)Notify physician 57.5 (550) 42.4 (405)Incident report necessary 24.2 (228) 75.8 (714)

Four patients on a busy surgical unit receive their 6 PM done of IVantibiotics 4 h late.


A patient receiving TPN feeding via an infusion pump is given 200 mL/hinstead of the correct rate of 125 mL/h for the first 3 h of the 24-hinfusion. The pump was reset to the correct rate after the change ofshift at 7 AM when the oncoming nurse realized that the pump wasset at the incorrect rate.


A patient admitted with status asthmaticus on 08/13 at 2 AM isprescribed albuterol (ventolin) nebulizers every 4 h. The nurseomits the 6 AM dose on 08/13 as the patient is asleep.


A physician orders oxycodone hydrochloride and acetaminophen(Percocet) 12 tabs for post-operation pain every 4 h. At 4 PM thepatient complains of pain, requests 1 pill and is medicated. At 6:30PM the patient requests a second pain pill. The nurse administersthe pill.


A patient is receiving a routine 9 AM dose of digoxin every day.Yesterdays digoxin level was 1.8 (the high side of normal). Adigoxin level was drawn at 6 AM today. At 9 AM the nurse holds thedigoxin because the lab value is not available yet.


TPN, total parental nutrition.

nurses classified each scenario as a medica-tion error (yes or no responses) and if theywould or would not report the situation toa physician or complete an incident report.

Classifying and reporting medication errorsdiffered between and within scenarios.

Some scenarios elicited common responsesin terms of classifying medication scenarios.



For example, most nurses (96.6%) respondedthat they would classify a fast running TPN(total parental nutrition) rate (200 mL/h for 3hours instead of the correct 125 mL/h) as adrug error; 92.1% would notify the physician;and 93.3% would complete an incident re-port. On the other hand, most nurses (91.8%)would not classify as a medication error thewithholding of a routine morning dose ofdigoxin because the digoxin blood level re-port was late. However, in this case 55.4%would notify the physician, but only 11.2%would complete an incident report.

For other scenarios, nurses had quite dis-parate responses. For example, nurses weresplit (55.5% versus 44.5%) in their classifica-tion of a scenario involving omission of a med-ication while the patient was sleeping. How-ever, once again more nurses would notify thephysician (62.7% versus 37.3%), yet were split(48.3% versus 51.7%) when it came to com-pleting an incident report.

In 5 out of the 6 scenarios, more nurseswould notify physicians than not notify themno matter how they first classified the scenar-ios. In 5 out of the 6 scenarios, more nurseswould not complete an incident report; thisdecision mirrored their original classificationof the scenario as either being a medicationerror or not being a medication error.

Table 4. Reporting medication errors

%

Item Yes (n) No (n)

I am usually sure what constitutes a medication error 92.6 (887) 7.4 (71)I am usually sure when a medication error should be reported using an

incident report91.3 (887) 8.7 (74)

Some medication errors are not reported because nurses are afraid ofthe reaction they will receive from the Nurse Manager

76.9 (737) 23.1 (221)

Some medication errors are not reported because nurses are afraid ofthe reaction they will receive from their peers

61.4 (590) 38.6 (371)

Have you ever failed to report a drug error because you did not think theerror was serious to warrant reporting?

52.9 (509) 47.1 (454)

Have you ever failed to report a medication error because you wereafraid you might be subject to disciplinary action or even lose yourjob?

19.6 (190) 80.4 (778)

Reporting medication errors

In addition to evaluating scenarios, nurseswere also asked, In your estimation, whatpercent of all drug errors are reported to thenurse manager by the completion of an inci-dent report?The mean percentage was 45.6,indicating that less than half of the nurses be-lieved that all drug errors are reported to anurse manager using an incident report.

Table 4 presents additional nurse responsesto statements about reporting medication er-rors. Most nurses indicated that they knewwhat constituted a medication error (92.6%)and when to report an error using an inci-dent report (91.3%). Reasons for not report-ing errors included afraid of manager reac-tion(76.9%), afraid of coworkers reactions(61.4%), and not thinking an error was seri-ous enough (52.9%). However, the majorityof nurses (80.4%) do not seem to fear disci-plinary action (losing ones job) because ofcommitting an error.

Links between nurse responses andnurse characteristics

Very few nurse characteristics were associ-ated with the survey responses including thenumber of errors nurses remembered makingover their career. Overall, nurses working in



an MCH versus an M/S setting reported theyperceived a greater percentage of medica-tion errors are reported. For example, nursesworking in neonatal intensive care units in-dicated they perceived a greater percentageof medication errors (52.5%) are reported tonurse managers than did nurses working inM/S units (eg, 35.3% oncology).

Even though nurses working in a MCH unitversus M/S unit responded as above, the re-lationship between type of unit and percent-age of perceived reported errors was weak(r = 0.21; P = .01). There also was a weak re-lationship between percentage of errors per-ceived reported and years of RN practice (r =0.15; P < .001). This means that these 2 RNcharacteristics, type of unit and years of prac-tice, explain very little about how nurses re-sponded to this question. Overall, while therewere a few significant relationships found be-tween the nurse characteristics and items onthe survey, these relationships were weak.

Limitations

The sample for this study was drawn from ahealthcare union, and therefore, the findingsmay not be generalizable to nonrepresentedRNs. Regarding the ranking of medicationerrors, there may be additional causes thatwere not identified on this studys survey.However, the top ranked causes from thisstudy could be a starting point for organiza-tions to address system issues. In addition, thescenarios were brief and did not provide sit-uational details. We have no way to know ifnurses read more into the scenarios than whatwas provided; however, lengthening surveyscan decrease overall return rates. The decisionwas made to retain the brief scenarios in orderto optimize the sample size.

NURSING IMPLICATIONS

Similar to other studies, no single or com-bination of nurse demographic characteristicswere strongly associated with nurse percep-tions of medication errors or the reporting ofmedication errors. Thus, all nurses in an or-

ganization may need help in identifying whatis a medication error, when to report it, andto whom. What this means for nurses work-ing on quality and patient safety programs isthat, most likely, there are no specific groupsof nurses to target for interventions or educa-tion. For example, inexperienced nurses arenot reporting more or less errors than do ex-perienced nurses. This once again emphasizessystemic problems at issue in regard to medi-cation errors.

This study calls attention to the need to clar-ify with nursing staff what constitutes a med-ication error. Interestingly, nurses were usu-ally sure what constitutes an error(92.6% yes,7.4% no) yet were not in high agreement withone another when given actual medicationscenarios (ie, 52.7% yes, 55.5% no). This studyhas identified a gap between the nurses per-ceived knowledge and his or her actual knowl-edge. It is clear that nurses need specific in-formation about what constitutes medicationerrors. The information gained from this studycan be used in educational programs designedto promote the recognition of these errors.

Now that we know nurses differ in theirperceptions as to what constitutes a medica-tion error, do organizations have clear guide-lines available as to what situations repre-sent medication errors? Regardless of ourpersonal opinions, traditions related to nurs-ings 5 rights of medication administration, orour unstated expectations, this study demon-strates that nurses are not on the same pageas to what is a medication error and when toreport to it.

Currently, organizations are having theirpatient safety programs examined in greatdetail by accrediting and licensing bodies.Paramount to any patient safety program is themedication error-reporting component. Thepurpose of having a comprehensive, accurate,and timely reporting program in place is tobe able to identify and correct knowledge andsystem defects immediately.

Similar to studies by Gladstone10 and Os-borne et al,12 this study identified differencesin reporting medication errors as well as per-ceived barriers to reporting. However, strong



barriers to reporting did not include fear ofdisciplinary action but were more in line withinterpersonal reactions from managers andstaff. Discussions among staff and nurse man-agers about the taboo subject of medicationerrors are desperately needed. Also, integrat-ing human factors theory into manageriallevel educational programs may help man-agers focus on system redesigns to reduceor eliminate reporting barriers within theirorganizations.

Finally, systems-oriented and critical think-ing should be promoted to enhance nursingjudgment to decrease the notion that certainerrors do not warrant reporting. All errors in-cluding near misses should be reported so thatorganizations have an opportunity to improvetheir patient safety programs.

Any practicing nurse knows that the causesof medication errors are both varied and com-plex. Because medication errors are such aconcern to the public, healthcare organiza-tions, and nurses themselves, this study wasundertaken to ask nurses about what theybelieve constitutes a medication error, whatis reportable, and what barriers to reportingexist. Additional dialogue and research with

nurses are needed. Questions to raise withnurses include the following:

1. How do nurses define medication er-rors?

2. Is there a unique and different definitionfor reportable medication errors versusnon-reportable errors?

3. Why is there a difference in nursing judg-ment between reporting medication er-rors to physicians and reporting medica-tion errors using incident reports?

4. What can organizations do to promotethe reporting of medication errors andnear misses?

While this study has generated some impor-tant questions, it also has provided some in-sights into medication errors and reporting.The knowledge gained from this study cancontribute to educational programs that pro-mote the recognition of medication errors.The knowledge also can assist with system re-designs to reduce or eliminate barriers to re-porting medication errors. Patient safety pro-grams can be strengthened through timely,accurate, and comprehensive reporting, ulti-mately ensuring the highest quality patientcare.

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Nurse perceptions of medication errors

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