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J Nurs Care Qual


Vol. 19, No. 3, pp. 209217
c 2004 Lippincott Williams & Wilkins, Inc.


Nurse Perceptions of
Medication Errors
What We Need to Know
for Patient Safety
Ann M. Mayo, DNSc, RN; Denise Duncan, RN
This study describes nurse perceptions about medication errors. Findings reveal that there are differences in the perceptions of nurses about the causes and reporting of medication errors. Causes
include illegible physician handwriting and distracted, tired, and exhausted nurses. Only 45.6% of
the 983 nurses believed that all drug errors are reported, and reasons for not reporting include
fear of manager and peer reactions. The study findings can be used in programs designed to promote medication error recognition and reduce or eliminate barriers to reporting. Key words:
medication errors, nursing, patient safety, reporting

EDICATION errors strike at the heart


of being a nursethe responsibility to
do good and avoid harm. Medication errors
have serious direct and indirect results, and
are usually the consequence of breakdowns
in a system of care. Direct results include
patient harm as well as increased healthcare
costs. Indirect results include harm to nurses
in terms of professional and personal status,
confidence, and practice.
Everyone concerned about patient safety
equates medication errors with serious risks
to patients. Medication errors also impact organizations and nurses. Ten to 18% of all reported hospital injuries have been attributed
to medication errors.1,2 Five percent of all
medication 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) and
the Southern California Kaiser Permanente Nursing Research Program for supporting this study.
Corresponding author: Ann M. Mayo, DNSc, RN, Kaiser
Permanente, California Division, 3033 Bunxer Hill,
San Diego, CA 92109 (e-mail: Ann.m.mayo@kp.org).
Accepted for publication: November 17, 2003

and Drug Administration (FDA) in 2001 were


fatal.3 United States data from 1993 indicate
that 7391 patients died from medication errors, and patient stays associated with medication errors increased by 4.6 days, with a resulting cost increase of $4685 per patient.1 In
the state of California alone, over 700 patients
die each year because of medication errors.4
MEDICATION ERRORS
Medication errors are typically defined as
deviations from a physicians order. Hospital
medication error rates can be as high as 1.9
per patient per day.5 Sources of errors include
illegibly written orders, dispensing errors, calculation errors, monitoring errors, and administration errors (ie, giving the wrong medication to the patient). Physicians, pharmacists,
unit clerks, and nurses can be involved in the
occurrence of medication errors.5 A single patient can receive up to 18 doses of medication
per day,6 and a nurse can administer as many
as 50 medications per shift.7 This places the
nurse at the front line when it comes to drug
administration accountability.8,9
Medication errors negatively affect nurses.
The psychological trauma caused by committing a medication error can be overwhelming to a nurse. First, nurses worry about the
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patient. Nurses may feel upset, guilty, and terrified about making a medication error. In
addition, they can experience a loss of confidence in their clinical practice abilities. Finally, they can feel anger at themselves as well
as the system.10
No studies have demonstrated strong relationships between nurse characteristics (ie,
age, years of practice, and education) and
number of medication errors.11,12 This would
seem to indicate that any nurse is potentially
at risk for making a medication error.
REPORTING MEDICATION ERRORS
Whether the nurse is the source of an error,
a contributor, or an observer, organizations
rely on nurses as front-line staff to recognize
and report medication errors. Several studies have demonstrated underreporting among
nurses.10,1215 Adding to the burden of reporting, more than 90% of the self-reports are
paper-based in California.16
Prevention of medication errors is linked
to accurate reporting of medication errors.
Reporting medication errors is dependent on
individual nurses decision making.15 Underreporting or not reporting medication errors
conceals flawed systems.1
Currently, self-reported medication errors
provide minimal information to organizations
because discrepancies, in terms of reportedto-actual rates, are widespread. Medication
errors are typically reported through institutional reporting systems such as incident
reports.15 Moore, however, estimated that organizations relying on incident reports to provide data miss up to 95% of the medication
errors.17 Reports are generated by the nurse
who identifies the error and then are forwarded to management, quality departments,
or risk management departments. Reporting
systems 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 error, and (4) willingness to overcome the embarrassment and fear of retaliation for having committed a medication administration
error.13

Nurses themselves believe only 25% of all


medication errors are reported using incident
reports. Only 3.5% of the nurses in the study
of Osborne et al believed that all medication
errors are ever reported.12 Nurse managers
and physicians also believe that medication
errors are underreported by nurses.13 Errors
of both commission and omission go unreported. Failure to administer a medication is
the most underreported error because nurses
perceive that patients will not be harmed
in this situation. Conversely, errors resulting
in overmedication are the most frequently
reported.13
Nurses deliberately decide to not report
some medication errors.18 It is estimated that
95% of medication errors are not reported because staff fear punishment.1 Disciplinary actions including job loss also affect reporting
rates.10,12,13,15 Staff nurses also fear being revealed and labeled as someone who has made
a medication error. Nurses and nurse managers report that they fear for the reputation
of their service or unit.13,19
Other reasons for not reporting medication
errors include disagreement over the definition of an error and the need to report it as
well as the degree of reporting effort, ie, time
to complete reports.15 Interestingly, Osborne
et al found that 15.8% of the nurses in their
study were unsure as to what situation constituted a medication error, and 14% were not
sure when to report the error.12
Most of these studies have limitations that
include an inadequate number of sites (eg,
one hospital) and units (eg, one medical and
surgical unit). It is difficult to know to what
degree the local culture influences nurse perceptions about medication errors in these limited site studies. Nonrandom sampling and
small sample sizes raise additional methodological issues.
No matter what reporting mechanisms,
policies, or procedures are in place, reporting medication errors remains dependent on
the nurses ability to detect medication errors and individual nurses decision making to
report medication errors. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) states that root cause analysis,

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while analyzing underlying systems, must include an assessment of the human and other
factors.20 For various reasons, possibly including nurse inability to detect medication
errors, perceptions that certain medication errors will not harm patients, or fear of consequences associated with reporting, nurses do
not report all detected medication errors. This
study was undertaken to understand more
about nurse perceptions of medication errors
and reporting.
METHOD
This study examined the perceptions of
medication errors among a large number of
randomly selected nurses in multiple settings.
More specifically, it was designed to investigate what nurses believe constitutes a medication error, what is reportable, and what
barriers to reporting exist. A self-report survey method was used to collect data for
this descriptive, correlational study. The current study replicated a study conducted by
Osborne et al by using a larger sample of
nurses 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 California
acute care hospitals represented the study
target population of 9000 acute care nurses.
Work settings consisted of private, government, military, and health maintenance organization hospitals.
A random sample of 5000 RNs was selected from the above population. According
to Roscoe21 a final sample size of 1000 RNs
would be optimal for this type of study. In
2 previous studies that used this studys instrument, response rates ranged from 61.9%12
to 79%.10 Historic response rates for surveys
mailed to UNAC RNs ranged from 25% to
40%. So, taking a conservative approach, 5000
UNAC RNs were mailed surveys in an attempt
to obtain a final sample size of approximately
1000 participants.

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Instrument
The Modified Gladstone12 was chosen to
collect data for this study. This instrument
measured (1) nurse perceived causes of medication errors (10 items); (2) percentage
of drug errors reported to nurse managers
(1 item); (3) types of incidents that would
be classified as (a) medication errors, (b) reportable to physicians, or (c) reportable using an incident report (6 items); and (4)
nurse views about reporting medication errors (6 items). For the purpose of this study,
one additional item was added to types of
incidents that reflected a therapeutic drug
level medication scenario. The last portion of
the instrument captured nurse demographic
data (11 items). Instrument content validity was determined acceptable by previous
investigators.10,12 In addition, Osborne et al
established reliability using the test-retest
method (0.78) in their sample.12
RESULTS
Nine hundred eighty-three RNs responded
to the survey, representing a 20% return
rate. Similar to nurses across the country, the
RN mean age was 44.6 years (range = 23
74 years; SD = 9.07). Nurses were primarily female (95%), had been practicing for an
average of 18.7 years (range = 145 years;
SD = 9.94), worked full time (62.7%), and
were in benefited positions (88.2%). Similar to the state of California RNs, the ethnic backgrounds of the study participants
were varied (49% white, 34% Pacific Islander,
8% Hispanic, 4% African American, and 4%
other), as was their highest level of education (11% diploma, 40% associate degree,
44% bachelors degree, 3% masters degree,
and 3% other). Nurses represented all working 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) practice
settings were represented (Table 1). Overall, the RNs responding to this survey were
representative of nurses working in Southern
California.

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Table 1. Nurse practice settings (Top 10


reported)
Setting
Adult critical care
Labor and delivery
NICU (neonatal intensive
care unit)
DOU/telemetry
Perioperative
Medical
Operating room
Surgical
Pediatrics
Emergency department

% (n)
13.5 (133)
9.7 (95)
9.4 (92)
7.9 (78)
6.1 (60)
5.8 (57)
4.8 (47)
4.5 (44)
4.2 (41)
3.5 (34)

DOU, definitive observation unit.

As part of the demographic survey, RNs


were also asked the number of medication errors they could remember making over the
course of their career. The mean number of
errors recalled was 4.9 per nurse (range =
0100; SD = 5.67). However, most nurses
(68.3%) recalled making 2 to 5 errors over
their career.
Analysis of the data focused on addressing the study aims that were to describe the

following:
1. nurse perceived causes of medication
errors,
2. nurse evaluation of medication scenarios,
3. nurse perceptions about reporting
medication errors, and
4. relationships between nurse characteristics (demographics) and perceptions regarding medication errors.
Causes of medication errors
Table 2 portrays the ranked causes of medication errors as perceived by the participating RNs. Nurses ranked the listed causes from
1 to 10, with 1 indicating most frequent cause
and 10 indicating least frequent cause. Mean
scores were calculated for each item and are
listed in the table. The top 3 ranked (out of
10) perceived causes of drug errors were the
following: (1) MD handwriting is difficult to
read or illegible, (2) nurses are distracted, and
(3) nurses are tired and exhausted.
Medication scenario evaluation
Based on 6 quite different scenarios presented to the nurses, Table 3 represents how

Table 2. Ranked causes of medication errors


Item
Drug errors occur when the physicians writing on the doctors order form is
difficult to read or illegible.
Drug errors occur when nurses are distracted by other patients, coworkers, or
events on the unit.
Drug errors occur when nurses are tired and exhausted.
Drug errors occur when there is confusion between 2 drugs with similar names.
Drug errors occur when the nurse miscalculates the dose.
Drug errors occur when the physician prescribes the wrong dose.
Drug errors occur when the nurse fails to check the patients name band with the
Medication Administration Record (MAR).
Drug errors occur when the nurse sets up or adjusts an infusion device incorrectly.
Drug errors occur when the medication labels/packaging are of poor quality or
damaged.
Drug errors occur when nurses are confused by the different types and functions
of infusion devices.
Ranking:

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

Mean

SD

3.92

2.60

4.15

2.98

4.30
4.55
5.20
5.46
5.87

2.82
2.35
2.16
2.50
3.06

6.13
7.52

2.37
2.53

7.74

2.13

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Table 3. Classifying and reporting of medication errors


%
Item
A patient misses his midday dose of oral ampicillin because he was in
x-ray for 3 h.
Drug error
Notify physician
Incident report necessary
Four patients on a busy surgical unit receive their 6 PM done of IV
antibiotics 4 h late.
Drug error
Notify physician
Incident report necessary
A patient receiving TPN feeding via an infusion pump is given 200 mL/h
instead of the correct rate of 125 mL/h for the first 3 h of the 24-h
infusion. The pump was reset to the correct rate after the change of
shift at 7 AM when the oncoming nurse realized that the pump was
set at the incorrect rate.
Drug error
Notify physician
Incident report necessary
A patient admitted with status asthmaticus on 08/13 at 2 AM is
prescribed albuterol (ventolin) nebulizers every 4 h. The nurse
omits the 6 AM dose on 08/13 as the patient is asleep.
Drug error
Notify physician
Incident report necessary
A physician orders oxycodone hydrochloride and acetaminophen
(Percocet) 12 tabs for post-operation pain every 4 h. At 4 PM the
patient complains of pain, requests 1 pill and is medicated. At 6:30
PM the patient requests a second pain pill. The nurse administers
the pill.
Drug error
Notify physician
Incident report necessary
A patient is receiving a routine 9 AM dose of digoxin every day.
Yesterdays digoxin level was 1.8 (the high side of normal). A
digoxin level was drawn at 6 AM today. At 9 AM the nurse holds the
digoxin because the lab value is not available yet.
Drug error
Notify physician
Incident report necessary

Yes (n)

No (n)

21.3 (200)
57.5 (550)
24.2 (228)

78.7 (740)
42.4 (405)
75.8 (714)

69.1 (643)
76.2 (719)
79.6 (751)

30.9 (288)
23.8 (224)
20.4 (193)

95.6 (911)
92.1 (877)
93.3 (893)

4.4 (42)
7.9 (75)
6.7 (64)

55.5 (518)
62.7 (587)
48.3 (449)

44.5 (415)
37.3 (349)
51.7 (481)

26.4 (248)
30.7 (291)
20.6 (191)

73.6 (692)
69.3 (656)
79.4 (736)

8.2 (76)
55.4 (527)
11.2 (103)

91.8 (853)
44.6 (424)
88.8 (818)

TPN, total parental nutrition.

nurses classified each scenario as a medication error (yes or no responses) and if they
would or would not report the situation to
a physician or complete an incident report.

Classifying and reporting medication errors


differed between and within scenarios.
Some scenarios elicited common responses
in terms of classifying medication scenarios.

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For example, most nurses (96.6%) responded


that they would classify a fast running TPN
(total parental nutrition) rate (200 mL/h for 3
hours instead of the correct 125 mL/h) as a
drug error; 92.1% would notify the physician;
and 93.3% would complete an incident report. On the other hand, most nurses (91.8%)
would not classify as a medication error the
withholding of a routine morning dose of
digoxin because the digoxin blood level report 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 disparate responses. For example, nurses were
split (55.5% versus 44.5%) in their classification of a scenario involving omission of a medication while the patient was sleeping. However, once again more nurses would notify the
physician (62.7% versus 37.3%), yet were split
(48.3% versus 51.7%) when it came to completing an incident report.
In 5 out of the 6 scenarios, more nurses
would notify physicians than not notify them
no matter how they first classified the scenarios. In 5 out of the 6 scenarios, more nurses
would not complete an incident report; this
decision mirrored their original classification
of the scenario as either being a medication
error or not being a medication error.

Reporting medication errors


In addition to evaluating scenarios, nurses
were also asked, In your estimation, what
percent of all drug errors are reported to the
nurse manager by the completion of an incident report? The mean percentage was 45.6,
indicating that less than half of the nurses believed that all drug errors are reported to a
nurse manager using an incident report.
Table 4 presents additional nurse responses
to statements about reporting medication errors. Most nurses indicated that they knew
what constituted a medication error (92.6%)
and when to report an error using an incident report (91.3%). Reasons for not reporting errors included afraid of manager reaction (76.9%), afraid of coworkers reactions
(61.4%), and not thinking an error was serious enough (52.9%). However, the majority
of nurses (80.4%) do not seem to fear disciplinary action (losing ones job) because of
committing an error.
Links between nurse responses and
nurse characteristics
Very few nurse characteristics were associated with the survey responses including the
number of errors nurses remembered making
over their career. Overall, nurses working in

Table 4. Reporting medication errors


%
Item
I am usually sure what constitutes a medication error
I am usually sure when a medication error should be reported using an
incident report
Some medication errors are not reported because nurses are afraid of
the reaction they will receive from the Nurse Manager
Some medication errors are not reported because nurses are afraid of
the reaction they will receive from their peers
Have you ever failed to report a drug error because you did not think the
error was serious to warrant reporting?
Have you ever failed to report a medication error because you were
afraid you might be subject to disciplinary action or even lose your
job?

Yes (n)

No (n)

92.6 (887)
91.3 (887)

7.4 (71)
8.7 (74)

76.9 (737)

23.1 (221)

61.4 (590)

38.6 (371)

52.9 (509)

47.1 (454)

19.6 (190)

80.4 (778)

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an MCH versus an M/S setting reported they
perceived a greater percentage of medication errors are reported. For example, nurses
working in neonatal intensive care units indicated they perceived a greater percentage
of medication errors (52.5%) are reported to
nurse managers than did nurses working in
M/S units (eg, 35.3% oncology).
Even though nurses working in a MCH unit
versus M/S unit responded as above, the relationship between type of unit and percentage of perceived reported errors was weak
(r = 0.21; P = .01). There also was a weak relationship between percentage of errors perceived reported and years of RN practice (r =
0.15; P < .001). This means that these 2 RN
characteristics, type of unit and years of practice, explain very little about how nurses responded to this question. Overall, while there
were a few significant relationships found between the nurse characteristics and items on
the survey, these relationships were weak.
Limitations
The sample for this study was drawn from a
healthcare union, and therefore, the findings
may not be generalizable to nonrepresented
RNs. Regarding the ranking of medication
errors, there may be additional causes that
were not identified on this studys survey.
However, the top ranked causes from this
study could be a starting point for organizations to address system issues. In addition, the
scenarios were brief and did not provide situational details. We have no way to know if
nurses read more into the scenarios than what
was provided; however, lengthening surveys
can decrease overall return rates. The decision
was made to retain the brief scenarios in order
to optimize the sample size.

NURSING IMPLICATIONS
Similar to other studies, no single or combination of nurse demographic characteristics
were strongly associated with nurse perceptions of medication errors or the reporting of
medication errors. Thus, all nurses in an or-

215

ganization may need help in identifying what


is a medication error, when to report it, and
to whom. What this means for nurses working on quality and patient safety programs is
that, most likely, there are no specific groups
of nurses to target for interventions or education. For example, inexperienced nurses are
not reporting more or less errors than do experienced nurses. This once again emphasizes
systemic problems at issue in regard to medication errors.
This study calls attention to the need to clarify with nursing staff what constitutes a medication error. Interestingly, nurses were usually sure what constitutes an error(92.6% yes,
7.4% no) yet were not in high agreement with
one another when given actual medication
scenarios (ie, 52.7% yes, 55.5% no). This study
has identified a gap between the nurses perceived knowledge and his or her actual knowledge. It is clear that nurses need specific information about what constitutes medication
errors. The information gained from this study
can be used in educational programs designed
to promote the recognition of these errors.
Now that we know nurses differ in their
perceptions as to what constitutes a medication error, do organizations have clear guidelines available as to what situations represent medication errors? Regardless of our
personal opinions, traditions related to nursings 5 rights of medication administration, or
our unstated expectations, this study demonstrates that nurses are not on the same page
as to what is a medication error and when to
report to it.
Currently, organizations are having their
patient safety programs examined in great
detail by accrediting and licensing bodies.
Paramount to any patient safety program is the
medication error-reporting component. The
purpose of having a comprehensive, accurate,
and timely reporting program in place is to
be able to identify and correct knowledge and
system defects immediately.
Similar to studies by Gladstone10 and Osborne et al,12 this study identified differences
in reporting medication errors as well as perceived barriers to reporting. However, strong

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barriers to reporting did not include fear of


disciplinary action but were more in line with
interpersonal reactions from managers and
staff. Discussions among staff and nurse managers about the taboo subject of medication
errors are desperately needed. Also, integrating human factors theory into managerial
level educational programs may help managers focus on system redesigns to reduce
or eliminate reporting barriers within their
organizations.
Finally, systems-oriented and critical thinking should be promoted to enhance nursing
judgment to decrease the notion that certain
errors do not warrant reporting. All errors including near misses should be reported so that
organizations have an opportunity to improve
their patient safety programs.
Any practicing nurse knows that the causes
of medication errors are both varied and complex. Because medication errors are such a
concern to the public, healthcare organizations, and nurses themselves, this study was
undertaken to ask nurses about what they
believe constitutes a medication error, what
is reportable, and what barriers to reporting
exist. Additional dialogue and research with

nurses are needed. Questions to raise with


nurses include the following:
1. How do nurses define medication errors?
2. Is there a unique and different definition
for reportable medication errors versus
non-reportable errors?
3. Why is there a difference in nursing judgment between reporting medication errors to physicians and reporting medication errors using incident reports?
4. What can organizations do to promote
the reporting of medication errors and
near misses?
While this study has generated some important questions, it also has provided some insights into medication errors and reporting.
The knowledge gained from this study can
contribute to educational programs that promote the recognition of medication errors.
The knowledge also can assist with system redesigns to reduce or eliminate barriers to reporting medication errors. Patient safety programs can be strengthened through timely,
accurate, and comprehensive reporting, ultimately ensuring the highest quality patient
care.

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